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THE    MODERN    HOSPITAL 

ITS    INSPIRATION  :   ITS    ARCHITECTURE 

ITS    EQUIPMENT:  ITS  OPERATION 


JOHN    ALLAN    HORNSBY,    M.  D. 

SECRETARY    HOSPITAL     SECTION,     AMEKICAN     MEDICAL     ASSOCIATION 
AMERICAN    HOSPITAL     ASSOCIATION,  AMEKICAN    ASSOCIATION    FO 
ADVANCEMENT  OF  SCIENCE,  AND  ASSOCIATION  OP  MILITARY  51 
GEONS    OF    THE    UNITED    STATES;    FIRST     LIEUTENANT, 
MEDICAL     RESERVE     CORPS,    U.      S.      ARMY 


AND 

RICHARD    E.    SCHMIDT,    Architect 

FELLOW   AMERICAN   INSTITUTE   OP   ARCHITECTS 


WITH    207     ILLUSTKAT/OXS 


III      MH  1  I'MI  \     WHI  UN'IIIIN 

W.    B.    SAUNDERS    COMPANY 

'9'3 


/3~v 


Copyright,  1013,  by  W.  B.  Saunders  Company 


«  A  ^  ^  3 

HI? 


PRINTED    IN    AMERICA 


PREFACE 


Tn  resigning  the  rranuscripl  of  this  book  to  the  publishers,  the  autho 
so  in  full  appreciation  of  its  many  shortcomings  and  of  its  unfinished  character. 
In  mitigation  of  the  o  Tense,  they  beg  to  recall  to  the  public  mind  the  sparsity  of 
hospital  literature,  am'  the  many  rapid  changes  thai  are  taking  place  in  the  science 

of  hospital  administration,  thai  would  render  the  literature  of  today  valueless  for 
tomorrow.  If  the  wisdom  of  the  main-  splendid  hospital  administrators  has  no1 
been  called  into  requisition  more  frequently  in  its  pages,  it  is  because  there  is 
practically  no  literature  from  the  pens  of  these  men  to  draw  upon  for  inspiration. 

If  one  of  the  authors  has  many  times  employed  illustrations  from  the  institu- 
tion over  which  he  has  the  honor  to  preside,  it  has  not  been  in  any  vainglorious 
spirit,  but  solely  for  the  reason  that  he  has  been  more  familiar  with  the  workings 
of  that  institution  than  with  many  that  may  perhaps  be  doing  things  far  bet- 
ter, and  many  of  its  methods  of  operation  arc  expressions  of  his  own  conviction-. 

This  book  has  the  tremendous  weakness  of  being  a  record  almost  wholly  of 
the  experiences  of  two  men,  and  the  authors  have  seriousljr  pondered  the  question 
of  how  far  a  discriminating  public  will  be  willing  to  follow  the  experiences  of  an 
individual  through  a  book  the  size  of  this.  In  justification,  it  may  be  urged 
that  the  history  of  mankind  is  a  composite  of  individual  life  stories,  and  it  is 
only  an  infinitesimal  number  of  these  millions  of  members  of  human  society  who 
have  here  ventured  to  record  their  own  experiences,  not  in  the  hope  of  permanent 
fame  or  glory,  but  merely  with  the  hope  that  there  may  be  contained  within  its 
pages  some  new  thought,  or  some  old  thoughl  clothed  in  new  garb,  that  may  help 
some  perplexed  and  tired  worker,  and  if  this  shall  come  to  pass,  the  hook  will  not 
have  been  written  in  vain. 

It  will  be  noted  that  in  many  parts  of  the  book  reference  i-  made  to  articles 
manufactured  by  individuals  and  firms,  and  the  names  and  addresses  of  these 
firms  are  given.  The  authors  and  the  publishers  are  quite  aware  of  the  oppor- 
tunity that  this  arrangement  offers  for  criticism,  and  perhaps  for  charges  ii\  inter- 
ested people  that  it  lias  been  done  by  way  of  advertising,  and  perhaps  for  a  price. 
In  answer  to  this,  the  authors  have  onlj  to  -ay  that  not  one  single  dollar  has  been 
paid  by  any  one,  excepting  the  authors,  for  any  purpose  in  connection  with  this 
book,  but  the  authors  and  publishers  feel  that  if  a  recommendation  of  any  arti- 
cle is  worthy  of  serious  attention  on  the  part  of  the  reader,  then  the  reader  lias 
also  aright  to  all  the  information  at  the  author-'  disposal,  and  this  information 
must  include  the  name  and   address  of   the  person   or   linn  fro  m   whom  the   article 

may  be  purchased. 

No  attempt  has  been  made  in  this  book  to  achieve  a  literary  success.  It  is 
merely  what  its  name  implies — a  hook  about  the  modern  hospital,  the  inspira- 
tions that  bring  it  into  being,  its  architecture,  its  equipment,  and  it-  adminis- 
tration. 

John  Allen  Hornsby, 

Km  ii  VSD   E.  S(  HM1DT, 
Chicago,  Ii.i.., 
Ha  ch,  1913. 

7 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/modernhospitalitOOhorn 


CONTENTS 


Introduction 17 

The  General  Hospital 17 

The  Charity  Hospital 18 

Mixed  Hospitals 19 

The  Private  Hospital 19 

The  Character  of  the  Hospital 20 

Financing  t  he  Hospital 20 

Running  Expenses 

Hospital  Architecture : 33 

The  Site :;  1 

Planning  the  Hospital 36 

The  Area  Per  Pat  ient 40 

Arrangement  of  Administrative  Units 40 

The  Admission  Rooms m 

The  Locker  and  Sterilizing  Rooms 43 

The  Kitchen 13 

The  Medical  Unit 15 

The  Surgical  Unit 47 

The  Operating  Suite 17 

Details  of  Structure 51 

Foundat  ions 51 

Walls  and  Facings 52 

Floor  Construction 55 

Roofing 58 

Floor  Surfacings 60 

Base  Coves 67 

Stairs  in  the  Hospital 69 

Partitions 71 

Furring 73 

Window  Frames .  I 

Woodwork 76 

Plastering  and  Wall  Finishes 7^ 

Interior  Painting 7^ 

Screens 79 

Weather  Strips 79 

Hardware 79 

Blanket  Warmer v" 

Permanent  Installat  ion    BO 

Boiler  and  Power  Supply sl> 

Heat  ing 

Pipe  Covering 

Lighting s~ 

Signaling  Systems 

Doctors'  Call  Systems 

Sewerage  and  Plumbing 

Water  Piping ' 

Plumbing  Fixtures 

Ventilation 

Ref  rigerat  ion „ 

Vacuum  Cleaning 

Elevators 108 

Divisions  of  a  <  ieneral  Hospital   

Administrative  Departments 

Kitchens 

Dining-rooms ' '  ' 


10  CONTENTS 

Hospital  Architecture  (Continued)  page 

Serving-rooms / 114 

Dining-rooms j 116 

Diet  Kitchens I 116 

Bakery ! 116 

Sun  Parlors I 117 

Apartments  for  Patients /. 117 

Private  Rooms J 117 

Private  Wards 1 119 

Public  or  Charity  Wards \ 119 

Infectious  Department 120 

Children's  Hospital ., 121 

A  New  Children's  Hospital 132 

Maternity  Hospital ) 139 

Architecture  of  the  Small  Hospital | 140 

Estimated  Costs  in  Detail 155 

Equipment  of  the  Hospital 157 

Fixed  Furnishings 157 

Vacuum  Cleaners 157 

Blanket  Warmers 159 

Sterilizers  for  Institution  Use 160 

Mattress  Sterilizers 163 

Utensil  Sterilizers 165 

Typhoid  Stool  and  Urine  Sterilizers 167 

Linen  Sterilizers 168 

Dressing  Sterilizers 169 

Water  Sterilizers 173 

Instrument  Sterilizers 174 

Combination  Set 175 

Furniture  in  the  Hospital 176 

Beds 176 

Springs 178 

Mattresses 178 

Children's  Beds 179 

Interns'  and  Nurses'  Beds 183 

Nurse's  Couch 183 

Bed  Rests 183 

Bed  Raisers 184 

Bed  Rollers 185 

Tables  in  the  Institution 187 

Ornamental  Tables 187 

Bedside  Tables 187 

Side  Tables 187 

Children's  Tables 188 

Serving  Tables 190 

Head  Nurse's  Desk 190 

Chairs  in  the  Institution 190 

Rockers 191 

Morris  Chairs 191 

Ward  Chairs - 191 

Wheel  Chairs. 192 

Commode  Chairs 194 

Chairs  for  the  Insane 195 

Rugs 197 

Screens 197 

Bed  Screens  in  Wards 197 

Private  Room  Screens 198 

Door  Screens 198 

Portable  Bath 199 

Decorations  in  Institutions 200 

Draperies 200 

Pictures 201 

Frescoes 201 

Books 202 

Receptacles  for  Clothing 202 

Equipment  of  the  Operating-rooms 204 

The  Furnished  Room 204 

Operating-table 206 

The  Shelf  Rack 209 


CONTENTS  1 1 

Equipment  of  tiik  Hospital  (Continued)  paof. 

Instrument  Tray  Stand 211 

Drum  Stands. 211 

Sponge  Rack 212 

Irrigator  Carl 212 

Instrument  Table 213 

Ann  Immersion  Stand 213 

Solution  Rack 213 

Goose-neck  Reflector 214 

The  Sinks 214 

Soap  Containers 215 

Instrument  Cabinet 215 

Purely  Technical  Apparatus 216 

Anesthetizing  Apparatus 217 

Cautery  Apparatus 218 

Bone  Drill 219 

Cystoscopic  Battery 222 

Special  Apparatus  for  Special  Departments 223 

Dressing-rooms 224 

I  Jressing  Carts 225 

( lynecologic  Table 225 

The  Kitchen  Equipment 226 

Ranges 226 

The  Kitchen  Table 226 

Disli  Warmers 227 

Steam  Table 228 

Dish  Washers 228 

The  Sinks 231 

Soup-stock  Boiler 231 

Vegetable  Peelers 232 

Meat  Cutters 232 

Bread  Slicers 233 

Vegetable  Cookers 234 

Coffee  and  Tea  Urns 236 

The  Diet  Kitchen 237 

Butcher  Shop 23S 

Store-rooms 240 

Pastry  Pant  ry 241 

Serving-room  Equipment 242 

Individual  Hot  Trays 242 

Food  Containers 244 

Food  Cars 245 

Equipment  of  the  Small  Private  Hospital 247 

Operation  of  the  Hospital 248 

The  Board  of  Directors 248 

How  Created 249 

Authority 250 

Committees 250 

Board  Meet ings 251 

Women's  Auxiliary  Boards 25 1 

Superintendent  of  the  Hospital 253 

Relation  to  the  Board 255 

Relation  to  Attending  Physicians 257 

Relation  to  House  Staff 260 

Relation  to  Nurses 

Relation  to  Business  Management- 261 

Relation  to  Patients  and  Public 262 

The  Medical  Staff 263 

The  Service  Staff 265 

Consulting  Staff 272 

The  Adjunct  Staff 273 

Relations  to  Superintendent  and  Hoard 273 

Relations  to  House  Staff 274 

Relations  to  Nursing  Corps 275 

The  Open-door  Policy 276 

Relation  of  the  Hospital  to  the  Medical  School 280 

House  Medical  Staff 284 

Duties  of  the  Modern  Intern 284 

Duties  of  Junior  Interns 285 


12  CONTENTS 

Operation  of  the  Hospital  (Continued)  page 

In  the  Surgical  Service 287 

In  the  Obstetric  Service 288 

In  Other  Departments 288 

Duties  of  Senior  Interns 289 

Methods  of  Choosing  Interns 290 

Rotation  or  Permanent  Service 293 

Limited  Rotation 294 

Relations  to  the  Superintendent 295 

Relations  to  Visiting  Physicians 296 

Relations  to  the  Nurses 297 

Relations  to  Patients 298 

Relations  to  Each  Other 299 

By-products  of  Internship 300 

Rules  for  Interns 301 

The  Modern  Trained  Nurse 304 

History  of  Nursing 304 

The  English  Nurse 306 

Preliminary  Training 309 

Age  and  Temperament 309 

Health  of  Probationer 311 

Training-school  in  the  Small  Hospital 312 

In  the  Large  General  Hospital 314 

Distribution  of  Nurses 315 

The  Flying  Squadron 316 

Training-school  Heads 316 

Discipline  in  the  School 316 

Teaching  Probationers 318 

The  Theoretic  Training 319 

Necessity  for  Rigid  Technic 321 

Length  of  the  Course ! 323 

Hours  of  Duty 323 

Home  Life  of  Pupils 324 

Undergraduate  Specials 325 

The  Graduate  Special 327 

Rules  for  Graduates 32S 

Graduates  in  Private  Service 329 

Nursing  and  the  Public 330 

The  Curriculum 332 

Male  Nurses 335 

Rules  for  Technical  Department 337 

Surgical  Rules 337 

For  Children's  Department 340 

For  Maternity  Department 343 

The  Surgical  Operating-rooms 351 

Preparation  of  Material 351 

Sponges  and  Gauze 351 

Making  Up  Sponge  Drum 352 

Hysterectomy  Gauze 352 

The  Long  Pack 352 

Laparotomy  Binder  Package 352 

Contents  of  the  Drum 352 

Bandages 353 

Solutions : 353 

Schleich  Solution 353 

Harrington  Solution 353 

Gelatin  Solution 353 

Thiersch  Solution 353 

Bichlorid  Solution 353 

Boric  Solution 354 

Iodin  and  Lysol  Solutions 354 

Ringer  and  Locke  Solutions 354 

Carbolic  Acid  Solution 354 

Beta-eucain  Solution 354 

Sterilization  of  Solutions 354 

Temperature  of  Solutions 354 

Silkworm,  Horsehair,  and  Silk 354 

Wax 354 

Care  of  Rubber  Goods 355 

Drainage 355 


CONTENTS  L3 

Operation  of  the  Hospital  (Continued)  paoe 

Soaps  355 

Make  Up  of  Trays 355 

Preparation  of  the  Room ::.~^ 

Kquipmcnl  of  Shelf  Stand 358 

The  ( >ther  Furniture 359 

Preparation  of  Patient 359 

Positions  on  Table 359 

Preparatory  Asepsis Win 

Rules  for  Nurses 360 

Preparation  of  Catgut 361 

Rubber  Cloves 365 

The  Test 366 

Sterilization 367 

"  Firsts"  and  ".Seconds" 367 

The  Surgical  Anesthetic 368 

Chloroform 369 

El  her 369 

Nitrous  Oxid-oxygcn 370 

Et  her  and  Gas  Combined 370 

Choice  of  Anesthetic 371 

Cost  of  Ancsthet  ics 372 

Rules  for  Administration 373 

Minor  Technic  in  the  Wards 376 

Spinal  Puncture 376 

Venesect  ion 377 

Direct  Transfusion 377 

Subcutaneous  Transfusion 377 

Paracentesis i!77 

Wet  Dressing  Box 378 

Preparation  of  Bodies  for  the  Morgue 378 

Department  of  Pathology 379 

Who  Shall  Do  the  Work? 379 

Where  the  Work  is  Done 381 

The  Ward  Laboratories 382 

The  Central  Laboratories 382 

Instruments  and  Apparatus 382 

Microscopes 382 

Incubators 383 

Laboratory  Sterilizers 383 

Microtomes ' 383 

The  Ovens 384 

Laboratory  Floors 384 

The  Hoods 384 

Laboratory  Sinks 384 

Test-tube  Board : 385 

Tables  and  Benches 386 

Laboratory  Paint 386 

Slide  Cases 386 

Laboratory  Lighting 387 

The  Dark'Room 387 

Post  mortem  Room 387 

Postmortem  Table 388 

The  Animal  Rooms 388 

Frozen  Section  Work 389 

The  Museum 390 

The  Refrigerators 390 

Pathology  for  Small  Hospitals 390 

Department  of  Hydrotherapy 392 

History  of  the  Science 392 

The  Douche 394 

The  Nauheim   394 

Dry  and  Vapor  Heat 394 

Passive  Exercises :>!>.". 

Massage 

Equipment 396 

Control  Table 197 

Needle  and  Shower 399 

The  Hospital  Pharmacy 4(X) 

Equipment  of  Drug  Store HH) 


14  CONTENTS 

Operation  of  the  Hospital  (Continued)  page 

The  Bottles  and  Labels 402 

Ward  Cabinets 402 

Methods  of  Dispensing 404 

Hospital  Dietetics 405 

Science  of  Special  Feeding 406 

Chemistry  of  Foods 406 

Caloric  Values  in  Diets 406 

The  Diet  Kitchen 407 

Charting  Special  Diets 408 

Common  Diet  Lists 409 

Diets  in  Small  Hospitals 411 

Milk  in  the  Hospital .412 

Sources  of  Supply 412 

Treatment  of  Milk 413 

Certified  Milk 414 

Milk  for  Children 415 

Sterilized  Milks 415 

Milk  Formulas 415 

The  Milk  Laboratory 419 

The  Work  Table 420 

The  Peptonizer 421 

The  Commercial  Milk 422 

Checking  Systems 423 

Isolation  and  Disinfection 425 

Diseases  of  Childhood 426 

The  Examining  Rooms 426 

Care  of  the  Exposed 427 

Complete  Isolation 428 

Raising  the  Quarantine 429 

The  Isolatable  Diseases 430 

Tuberculosis  and  Pneumonia 430 

Typhoid  Fever 431 

Erysipelas 432 

Cerebrospinal  Meningitis 433 

Gonorrhea 433 

Syphilis 434 

Pyocyaneus 435 

Pyogenic  Infections 435 

Other  Pyogenic  Organisms 435 

Processes  of  Disinfection 436 

Heat 436 

Fluids 436 

Chemical  Agents 437 

Gases 438 

Model  Isolation  Unit 440 

The  ,-r-Ray  Department 446 

Equipment 447 

Portable  Apparatus 448 

Stereoscopic  Apparatus 449 

Protective  Devices 450 

Plans  of  the  X-Ray  Suite 452 

Patients'  Records  and  Record  Keeping 453 

History  Taking 454 

Laboratory  Routine 457 

Physical  Examination 462 

Daily  Record 463 

Nursing  Chart 463 

Permit  for  Operation 464 

History  of  Operation 465 

Filing  and  Indexing 467 

Who  Shall  Have  Access  to  Records? 471 

X-Ray  Record 473 

Who  Shall  Have  Access  to  X-Ray  Plates? 475 

Social  Service  and  Outpatient  Work 477 

Organized  Charities 477 

The  Dispensary 479 

Outpatient  Hospital  Service 481 

Parole  of  Children 482 


COXTI         -  1") 

Operation  of  the  Hospital  {Continued)  paoe 

Business  Management is i 

The  I  tffice  w  I 

Admission  of  Patients    485 

The  Room  Board 188 

Disposition  of  Effects    189 

Hospital  Visitors 190 

To  Private  Patients i"i 

In  Large  Wards I'M 

\  isitors  in  Maternity 182 

Visitors  io  Children  a  Section I'll 

Social  Visits  of  Physicians 195 

Devices  for  Handling  Visitors 196 

The  Hospital  Telephone 198 

Physicians'  Register 499 

The  Condition  Hook 

Intern  Call  Systems 502 

The  Key  Board 502 

Repairs  in  the  Hospital 503 

Disposition  of  the  Dead 504 

Effecl  s  of  t  he  Dead 505 

Papers  to  Certify 506 

( obtaining  Autopsies 507 

Ambulance  Service 508 

The  Horse  Vehicle 508 

The  Auto  Ambulance 509 

Comparative  Costs 509 

Hospital  Accounting 511 

Income 511 

Expenditures 514 

( leneral  Accounts 518 

Investment  Accounts 518 

Insurance 521 

Analysis  of  Expenditures  Book 522 

Balance  Sheet 524 

Pel  ty  Cash  Book 527 

House  Count 52S 

Superintendent's  Report 531 

Financial  and  Stat  istical  Statement 533 

Purchase  of  Supplies 535 

Requisit  ions 536 

The  Storekeeper 537 

Medical  and  Surgical  vSupplies 539 

Gauze  and  Cotton 539 

Linens  and  Cottons 541 

Blankets 542 

Coats,  Gowns,  Uniforms 543 

Enamel  Ware 545 

Irrigators  and  Glassware 546 

Miscellaneous  Rubber  Goods 547 

Sheets  and  Blankets .".17 

Other  Rubber  Supplies 548 

Consumable  Supplies 550 

Meat  and  Fish 550 

Eggs 554 

Butter 556 

Fresh  Fruits 558 

Root  Vegetables 560 

Canned  Vegetables 562 

Canned  Fruits 565 

Olives 566 

Coffee 566 

Cooking  and  Kitchen  Ware 568 

Granil  e  Ware 568 

Enamel  Ware 569 

Tinned  Steel 569 

Copper  Ware 569 

Aluminum 569 

Cutlery  and  Table  Ware 570 

China  and  Glassware 572 


16  CONTENTS 

Operation  of  the  Hospital  (Continued)  •  page 

Soaps 573 

Janitors'  Supplies 577 

Housekeeping  Department 580 

The  Housekeeper 580 

Feeding  the  Hospital 582 

Kitchen  Operations 582 

Divisions  of  Table  Service 585 

Menus  for  the  Help 586 

Menus  for  Patients 586 

Feeding  the  Small  Hospital 589 

Cost  of  Private  versus  Charity  Patients 591 

Employment  of  the  Help 592 

The  Trained  Help 593 

The  Common  Help 594 

Cleaning  the  Hospital 596 

Institution  Laundry 598 

Laundry  Problems 599 

Capacity  of  the  Laundry 601 

Laundry  Machinery 603 

Laundry  Space 607 

Laundry  Rules 608 

Laundry  Costs 611 

Handling  the  Linens 612 

Steam,  Water,  and  Power 615 

The  Installation 616 

The  Linen  Rooms 621 

Laundry  Chutes 624 

Destruction  of  Waste 626 

Sanitary  Garbage  Destroyer 627 

Combination  Garbage  Plant 629 

The  Institution  Bakery 631 

Cost  of  Home-made  Bread 631 

Equipment  of  Home  Bakery 631 

Cost  of  Bakers'  Bread 632 

Index 633 


INTRODUCTION 


Problems  incident  to  the  creation  and  operation  of  institutions  intended  for 
the  care  of  the  sick  are  practically  the  same  whether  the  object  be  a  sanitarium, 
an  asylum  for  the  mentally  diseased,  a  home  for  the  helpless,  old  or  young,  or  a 
general  or  special  hospital. 

Communities,  like  individuals,  inevitably  reach  a  parting  of  the  ways  in  the 
course  of  their  lives  and  adventures,  and  one  of  two  things  must  happen:  either 
they  warp,  shrivel  up  and  stagnate  in  development  and  eventually  become  social 
defectives,  to  live  on  the  bounty  of  others;  or  they  grow  to  strong,  virile  maturity 
that  brings  with  it  those  responsibilities  that  have  for  their  object  the  care  and 
guardianship  of  the  unfortunate  and  helpless.  When  such  an  epoch  comes  in  the 
life  of  a  community,  the  stimulus  is  usually  a  present  and  a  pressing  necessity. 
'flic  inspiration  behind  the  demand  will  be  the  same  no  matter  what  class  of  insti- 
tution is  required — the  growing  community  and  the  increasing  number  of  people 
intended  to  be  benefited,  the  distance  to  the  nearest  institution  of  the  same  nature 
that  has  been  utilized  in  the  past,  the  present  ability  of  the  community  to  bear 
the  new  burden  independent  of  outsiders — all  these  questions  present  themselves 
when  such  new  philanthropic  enterprises  are  contemplated. 

Usually,  the  first  necessity  will  be  for  a  general  hospital  to  care  for  and  cure  the 
vasl  majority  of  diseases;  and  so  great  and  varied  and  many  sided  is  this  question 
that  in  its  investigation  we  will  naturally  come  upon  many  side  questions,  which 
would  likewise  arise  in  the  event  that  some  special  institution  was  under  discus- 
sion, and,  therefore,  it  may  be  profitable  for  us  to  diverge  occasionally  and  follow 
some  of  these  by-paths  of  thought  to  their  logical  end. 

THE  GENERAL  HOSPITAL 

General  hospitals  divide  themselves  automatically  into  three  classes:  first, 
those  that  are  wholly  charitable  in  their  good  office;  second,  those  that  are  partly 
given  over  to  charity  and  partly  to  pay  patients;  third,  those  that  accept  only  pay 
patients. 

In  nearly  every  part  of  the  world  hospitals  that  do  charity  work  only  are  sup- 
ported by  the  organized  public— that  is,  either  by  the  state  or  the  municipality; 
in  such  institutions  the  very  poorest  class,  composed  of  people  who  are  permanent 

charges  upon  society,  are  cared  for,  and  in  these  the  primary  demand,  at  least 
in  the  past,  has  been  in  the  direction  of  economy  in  operation.  That  such  a 
policy  is  a  mistaken  one.  and  not  in  conformity  with  modern  civilization  and  phi- 
lanthrophy,  needs  no  argument. 

Hospitals  that  do  a  considerable  amount  of  charity,  and  at  the  same  time  pro- 
vide accommodation  for  a  certain  proportion  of  private  pay  patients,  occupj  a 
vastly  different  plane  in  society  from  those  thai  do  only  charity  work.  Their 
contemplation  brings  us  to  a  more  inviting  field.  These  establishments  must  have 
their  initiative  and  make  up  their  deficit--  from  one  or  several  sources;  sometimes 

2  17 


18  INTRODUCTION 

the  institution  will  be  created  and  supported  in  large  part  by  a  peculiarly  fortunate 
member  of  the  community  who  has  the  necessary  wealth  at  his  disposal,  coupled 
with  a  philanthropic  mind.  Frequently  a  religious  order,  a  church  organization, 
may  inaugurate  the  movement  for  such  a  hospital,  and  rally  to  its  support  for  the 
success  of  the  enterprise  a  sufficient  number  of  adherents  of  the  faith  to  guarantee 
the  creation  and  support  of  the  institution.  Oftentimes  the  movement  is  a  racial 
one,  and  the  first  thought  in  the  conduct  of  such  a  hospital  will  be  the  care  of  the 
particular  transplanted  race  that  has  inaugurated  the  movement  and  made  pos- 
sible its  achievement.  Again,  the  inspiration  may  be  independent  of  any  special 
faction  or  class  or  creed,  and  where  public  subscriptions  behind  a  stimulus  of  good 
citizenship  will  build  the  hospital  and  afterward  supply  a  large  measure  of  its 
support. 

Occasionally  an  institution  founded  by  one  of  these  classes  in  the  community 
will  diverge,  owing  to  changed  conditions,  and  become  the  particular  philanthrophy 
of  an  entirely  different  class;  as,  for  example,  a  hospital  instituted  and  supported 
for  a  length  of  time  by  public  subscriptions  may  be  the  recipient  of  a  large  individual 
gift  in  the  shape  of  an  endowment  or  bequest,  oftentimes  carrying  with  it  certain 
conditions  which  may  change  the  whole  character  of  the  institution. 

Now  let  us  consider  a  hospital  inaugurated  with  some  ulterior  purpose  in  view 
and  intended  to  be  self-supporting  from  charges  against  pay  patients.  Very 
often  this  class  of  institution  will  have  its  birth  in  the  business  acumen  of  one  or  a 
coterie  of  physicians  who  have  in  mind  a  better  care  for  their  patients  than  can  be 
given  in  some  already  existing  institution,  in  which  part  of  the  support  may  come 
from  free  gifts  on  the  part  of  the  public.  Many  times  such  an  establishment  re- 
sults from  the  concerted  action  of  well-to-do  people  of  the  community,  where  there 
is  already  in  existence  a  charity  hospital  having  no  accommodation  for  those  who 
can  afford  to  pay  for  their  care. 

THE  CHARITY  HOSPITAL 

There  are  some  advantages  and  many  disadvantages,  taking  a  broad  view- 
point, in  all  three  classes  of  institutions  which  we  have  named. 

Regarding  charity  hospitals  there  is  too  commonly  an  impression  in  the  public 
mind  that,  since  the  patients  to  be  benefited  are  public  charges,  contributing  no  part 
toward  their  support,  almost  anything  is  good  enough  for  them;  a  place  to  be  housed 
— without  much  regard  to  the  kind  of  housing;  indifferent  medical  attention;  more 
indifferent  nursing;  the  cheapest  food;  the  most  rudimentary  and  often  obsolete 
methods  of  treatment — these  seem  too  often  to  meet  the  requirements  of  even  en- 
lightened, self-satisfied  communities.  These  disadvantages  in  the  public  charity 
hospital  are  overcome  almost  wholly,  when  they  are  overcome  at  all,  by  an  aroused 
public  conscience — as,  for  instance,  within  the  past  few  years  in  some  American 
communities,  where  charity  boards,  state  officials,  and  municipal  commissions 
have  been  arraigned  before  the  bar  of  public  opinion,  and  even  in  the  courts  of 
law,  for  wanton  neglect  of  their  obligations  toward  the  helpless  charges  committed 
to  their  care.  So  great  indeed  seems  to  be  the  change  in  the  public  mind  within 
recent  years,  that  it  is  certain  the  day  is  not  far  distant  when  the  public  hospital 
will  become  an  object  of  pride  to  society,  where  the  poor  will  have  the  same  advan- 
tages in  the  treatment  and  cure  of  disease  as  private  patients  in  more  exclusive  insti- 
tutions; indeed,  it  may  be  frankly  stated  that  there  are  even  now,  thanks  to  this 
aroused  public  conscience,  some  institutions  in  several  of  the  states  of  the  Ameri- 
can union  to  which  even  well-to-do  people  seek  admission,  because  of  the  high  order 


THE    PRIVATE    HOSPITAL  L9 

of  administration  and  of  their  humane  and  modern  methods.  The  insane  asylums 
stand  out  boldly  as  examples  of  this  new  era  of  our  civilization,  owing  somewhat, 
perhaps,  to  the  peculiarly  helpless  condition  of  the  wards  of  the  public  and  the 

sympathy  aroused  in  their  behalf. 

MIXED  HOSPITALS 

The  quasi-public  hospitals,  which  provide  a  part  of  their  service  for  charity 
and  another  for  those  who  can  afford  to  pay,  have  also  their  advantages  and  disad- 
vantages. 

Naturally,  the  private  patients  will  come  to  these  institutions  by  election,  and, 
therefore,  the  service  received  must  be  of  a  sufficiently  high  order  to  attract  them; 
thus,  this  part  of  the  question  will  take  care  of  itself,  in  a  general  way. 

The  charity  patient  will  not  always  fare  so  well.  Here,  too,  in  late  years  the 
public  conscience  has  been  aroused  and  in  rather  a  unique  way: 

The  time  is  past  when  administrators  of  such  an  institution  can  go  to  the  pub- 
lic and  command  support  on  the  score  of  duty  and  good  citizenship.  Charity 
givers  and  philanthropists  of  large  means  are  usually  men  and  women,  who,  hav- 
ing succeeded  in  their  business  life  by  reason  of  mental  superiority  and  discrimi- 
nating methods,  are  apt  to  ask  embarrassing  questions  on  being  approached  for 
donations;  statistical  reports  of  stewardship,  setting  out  in  detail  the  disposition 
of  funds  employed  in  the  past  will  lie  required.  It  will  not  do  any  longer  to  appeal 
to  the  wealthy  for  donations  on  the  score  that  the  institution  lias  been  run  during 
the  past  year  at  a  low  per-capita  cost,  because  the  discriminating  philanthropist 
will  pry  beneath  these  figures  to  ascertain  what  has  been  done  in  a  humanitarian 
way  as  measured  by  the  medical  skill  and  possibilities  of  the  time.  Modern  thought 
along  these  lines  has  been  a  vast  advantage  in  these  mixed  hospitals,  compelling 
administrators  to  give  to  the  free  patient  a  higher  order  of  service  and  a  better 
scientific  care  than  formerly. 

THE  PRIVATE  HOSPITAL 

The  private  hospital  of  the  day,  in  which  all  of  the  patients  are  expected  to 
pay  in  full  for  the  care  they  receive,  is  one  of  the  most  interesting  public  problems 
of  the  time.  It  is  dependent  for  its  prosperity  on  the  number  of  patients  attracted, 
and  this  brings  about  a  healthy  competition  in  service  and  care.  Usually,  the 
physician  is  responsible  for  the  patient's  entry  into  the  institution.  If  the  doctor 
is  financially  interested  in  the  establishment,  he  is  certain  to  be  even  more  interested 
from  a  financial  standpoint  in  the  proper  care  of  his  patient,  and,  however  much  he 
may  desire  to  support  the  institution  where  his  investment  lies,  he  will  rarely  be 
willing  to  do  so  at  the  expense  of  his  own  standing  with  his  patient  and  his  patient's 
family;  and  even  if  we  are  willing  to  endow  the  doctor  with  the  most  sordid  and 
selfish  motives,  we  must  yet  give  him  credit  for  a  certain  business  judgment,  which 
will  coerce  him  into  a  demand  for  the  very  besl  scientific  care  of  his  patient. 

In  a  very  large  way  we  can  look  to  this  class  of  hospitals  for  new  standards, 
for  the  latest  scientific  methods  in  the  treatment  of  disease,  for  the  highest  order  of 
technical  skill.  If,  moreover,  all  these  are  found  in  one  hospital,  and  tor  a  favored 
class,  it  will  not  be  very  long  before  the  public  will  demand  their  introduction 
in  the  care  of  less  fortunate  patients,  and  in  this  wise  the  community  will  gain  for 
its  public  charges  the  same  standards  in  force  in  behalf  of  the  more  fortunate  of  it^ 
members. 


20  INTRODUCTION 


THE  CHARACTER  OF  THE  HOSPITAL 

We  have  now  considered  some  of  the  underlying  thoughts  which  will  move  a 
community  to  build  or  propose  to  build  a  hospital,  and  which  will  probably  lead 
to  the  particular  kind  of  hospital  demanded.  But  there  are  other  considerations, 
local  in  character,  which  must  be  reckoned  with.  It  may  be  a  mining  community, 
in  which  the  vast  majority  of  the  people  are  in  moderate  circumstances  with  fixed 
incomes,  small,  but  constant;  a  milling  neighborhood,  where  the  conditions  would 
be  practically  the  same;  again,  it  maybe  the  site  of  railroad  shops  or  shipyards; 
here  the  kind  of  hospital  will  be  decided  upon  by  the  employers  of  the  labor,  the 
corporations. 

Local  conditions  leading  to  certain  classes  of  diseases  will  frequently  determine 
the  character,  as,  for  example,  where  lung  troubles  and  the  catarrhal  affections 
are  most  frequent;  or,  in  the  south,  where  the  micro-organisms  of  malaria  have  their 
abiding  place;  or  a  region  of  mountain  fevers,  or  in  those  low,  humid  areas  where 
the  gastro-intestinal  diseases  are  common.  If  it  be  some  port  of  entry  where  foreign- 
ers come  and  go,  and  where  the  communicable  infections  are  likely  to  prevail, 
isolation  is  a  prerequisite. 

In  a  railroad  town  where  the  hospital  is  to  be  built  for  the  accommodation  of 
railroad  men,  perhaps  to  be  built  and  supported  by  the  railroad  corporation  itself, 
the  question  is  rather  an  easy  one,  and  perhaps  of  the  simplest  form.  Surgical 
wards  for  injured  men,  medical  wards  for  sick  railroad  employees,  and  it  may  be 
a  genito-urinary  department,  will  meet  almost  all  the  requirements.  If  it  is  a 
milling  town,  where  the  men  work  among  iron  or  steel  filings,  or  in  an  atmosphere 
filled  with  wool  and  cotton  particles  or  charged  with  noxious  gases,  there  must 
be  special  departments  for  the  eye,  ear,  nose,  and  throat. 

When  the  hospital  is  to  be  located  where  the  employed  men  reside,  the  further 
question  naturally  presents  itself,  is  it  intended  to  take  care  of  the  families  of  the 
workmen,  and  if  so,  is  it  to  be  done  free  of  charge  or  for  a  modest  sum?  It  will 
then  be  necessary  to  include  wards  for  the  women,  not  only  for  those  sick  with 
ordinary  afflictions,  but  with  special  women's  diseases.  As  it  is  coming  nowadays 
to  be  a  necessity  for  women  to  retire  to  a  hospital  for  their  maternity,  an  obstetric 
department  will  be  needed. 

Not  only  the  ordinary  diseases  of  children  must  be  considered,  but  malnutrition, 
which  brings  in  its  wake  provision  for  their  diet,  either  in  the  shape  of  wet-nurses, 
milch-goats,  healthy  cows,  kept  and  milked  in  a  sanitary  way,  or  some  form  of 
prepared  milk  food.  For  the  communicable  diseases  of  childhood  isolation  wards 
must  be  supplied. 

FINANCING  THE  HOSPITAL 

Having  considered  somewhat  the  character  and  the  size  of  the  hospital  most 
needed,  out  next  thought,  and  certainly  the  most  important  one,  has  to  do  with  the 
raising  of  money  to  build  the  institution  and  to  provide  for  its  permanent  sup- 
port. We  must  revert  again  to  our  previous  classification  of  general  hospitals. 
The  charity  hospital,  pure  and  simple,  will  necessarily  be  financed  by  the  political 
body  inaugurating  it — that  is,  the  legislative  assembly  will  appropriate  the  money 
to  build  it,  with  at  least  an  implied  obligation  to  appropriate  annually  thereafter 
the  necessary  funds  for  its  support.  We  need  only  say  a  few  words  in  this  behalf. 
Until  very  recently  public  hospitals  have  been  miserably  provided  for,  and  it  is 
within  common  knowledge  that  the  administrator  even  now  held  highest  in  the 
esteem  of  the  appointive  power  is  he  who  has  been  able  to  operate  his  institution 


FINANCING    THE    HOSPITAL  21 

for  the  least  money,  without  much  regard  to  the  character  of  the  service  given  to 
the  patients.  The  administrator,  having  received  definite  orders  from  his  masters, 
the  public,  has  merely  obeyed  these  commands  and  operated  his  institution  in  the 
manner  required.     It  has  not  been  his  fault  if  the  orders  have  been  mediaeval  and 

if  the  policies  transmitted  are  unhumane,  unenlightened,  unscientific,  and  even  in- 
human. If  legislators  have  demanded  such  an  administration,  they  again  have 
merely  taken  their  orders  from  the  public  which  has  elected  them  to  office  and 
continues  them  in  office  only  so  long  as  they  do  the  public  bidding.  If  public 
hospitals  are  to  be  administered  in  step  with  the  scientific  tone  of  the  time,  and  if 
the  wards  of  the  public  are  to  have  the  scientific  skill  in  the  cure  of  their  diseases 
to  which  they  are  entitled  by  reason  of  the  modern  status  of  medicine  and  surgery, 
the  orders  must  come  direct  from  the  public  conscience,  as  expressed  in  a  determi- 
nation for  larger  appropriations  for  these  institutions.  There  is  rarely  a  protest 
if  the  salaries  of  politicians  are  increased,  or  if  new  offices  are  created  or  new  public 
buildings  proposed.  But  one  who  may  have  the  curiosity  to  consult  the  legislative 
annals  in  any  given  state,  over  a  long  period  of  time,  will  find  that  to-day,  notwith- 
standing the  increased  cost  of  everything  in  the  way  of  living,  the  amounts  of  money 
appropriated  for  public  institutions  are  about  the  same  as  many  years  ago,  and 
administrators  are  expected  to  operate  their  institutions  within  those  limited 
means.  A  proposal  from  a  governor  or  mayor  or  legislator  for  an  increase  in  appro- 
priations for  a  public  institution  is  usually  met  with  the  cry  of  graft,  the  inference 
being  that  political  henchmen  are  to  be  fed  at  the  public  crib.  And  so  the  pro- 
posal dies  away,  and  so  it  will  continue  to  die  away  until  the  public  recognizes  that 
the  hospital  of  to-day  cannot  be  operated  upon  the  same  standards  and  with  the 
same  simplicity  that  obtained  twenty  years  or  even  ten  years  ago.  And  when  that 
time  comes,  public  hospitals  will  not  be  the  disgrace  they  are  to-day. 

Let.  us  turn  now  to  a  more  attractive  and  inviting  field  of  speculation,  the 
financing  of  another  class  of  general  hospitals,  the  one  inaugurated  by  private 
enterprise,  by  philanthropy  and  private  charity  combined.  There  a  proportion 
of  the  patients  is  treated  free  and  another  proportion,  large  or  small,  is  supplied 
with  accommodations  for  which  they  must  pay.  We  ought,  perhaps,  to  set  out 
upon  this  discussion  with  the  flat  declaration  that  no  institution  that  proposes  to 
take  care  of  any  considerable  percentage  of  its  patients  free  can  be  self-support- 
ing. In  other  words,  the  pay  patients  of  an  institution  should  not  be  compelled 
to  do  more  than  pay  for  their  own  care.  They  should  not  be  coerced  into  helping 
pay  the  expenses  of  others.  That  money  should  come  by  voluntary  contribution, 
which  is  not  the  case  when  a  private  patient  is  charged  for  the  service  he  receives 
more  than  it  costs.  When  we  think  of  a  part  pay  and  part  free  hospital,  we  must 
settle  definitely  the  number  of  free  patients  to  be  provided  for  and  then  figure 
upon  financing  the  institution  for  that  many  free  patients,  leaving  the  private 
work  in  the  hospital  to  merely  take  care  of  itself. 

In  the  first  place,  the  institution  must  be  planned  along  the  lines  of  our  pre- 
vious discussion;  and  then  the  money  must  be  raised  with  which  to  build  it,  since 
no  part  of  the  building  fund  is  at  hand  from  any  private  patients  to  be  received. 
Later  on  we  shall  discuss  the  major  items  of  expense  in  building  the  hospital;  at 
this  time  we  are  concerned  only  with  its  subsequent  support  and  with  methods  for 
raising  the  money  required  to  build  it.  Of  these  there  are  a  number.  Naturally. 
the  easiest  and  most  satisfactory  is  by  direct  gift  from  some  wealthy  member  of 
the  community,  or  from  some  wealthy  philanthropist  whose  interests  are  there. 
Such  a  donation  may  be  direct,  during  his  lifetime  and  under  conditions  which  he 
himself  may  dictate,  and  in  two  parts,  one  for  the  building  of  the  institution  and 


22  INTRODUCTION 

one  for  its  subsequent  support;  or  it  may  come  in  his  will  by  bequest.  In  this  case 
the  restrictions  usually  intended  by  the  giver  will  give  direction  to  the  subsequent 
character  and  conduct  of  the  institution. 

The  next  best  method  of  raising  funds  for  the  building  and  support  of  the  hos- 
pital or  similar  institution  will  be  by  way  of  some  organized  body  of  citizens,  pre- 
ferably a  body  having  a  corporate  and,  therefore,  permanent,  existence,  a  church 
organization,  or  one  or  another  of  the  religious  orders  having  some  binding  issue, 
such  as  the  religious  thought,  as  its  moving  purpose.  Such  initiative  has  many 
advantages  and  some  disadvantages.  The  cohesive  power  is  great  in  a  church  or 
religious  organization  and  is  not  likely  to  be  lost  in  the  passage  of  time,  and,  there- 
fore, support  pledged  to-day  to  a  hospital  in  the  community  will  not  be  lost  unless 
for  excellent  reasons.  And  usually  an  organization  with  such  a  serious  purpose  has 
certain  ideals  and  certain  standards  which  will  be  infused  into  any  creature  to  which 
it  gives  birth.  There  is  no  greater  human  motive  than  the  religious  impulse,  and 
the  adherents  of  a  faith  will  rally  round  a  standard  set  by  their  leaders,  and  there- 
fore a  hospital  instituted  under  such  auspices  is  likely  to  be  permanently  sup- 
ported, and  to  that  extent  such  support  has  its  advantage.  Unfortunately,  we 
occasionally  find  such  religious  thought  not  quite  abreast  of  the  day  from  the 
medical  and  surgical  standpoint,  and  it  is  possible  for  a  hospital  operated  by  a 
religious  society  or  the  leaders  of  a  religious  sect  to  fall  somewhat  short  of  the 
scientific  requirements  of  the  time;  but  usually  this  tendency  is  combated  and 
overcome  by  a  secondary  leadership  or  a  demand  which  may  emanate  from  the 
medical  staff  or  the  lay  members  of  the  sect,  and  which  will  serve  to  keep  the 
institution  up  to  present-day  standards. 

Another  form  of  support  for  an  institution  of  this  character  will  be  rather 
racial  than  sectarian.  Next  to  the  religious  motive  there  is  hardly  an  impulse 
that  moves  the  heart  so  completely  as  that  of  love  of  country.  In  some  communities 
there  are  large  numbers  of  transplanted  foreigners  from  a  land  beyond  the  seas, 
and,  far  from  home,  they  oftentimes  are  somewhat  clannish,  as  expressed  in  a  desire 
of  some  members  to  help  the  less  fortunate.  There  are  German  hospitals  and 
French  hospitals  and  Scandinavian  hospitals.  Usually  such  support  will  be  almost 
community  wide,  and  the  support  of  the  hospital  will  be  in  proportion  to  the 
strength  of  the  race  in  the  community,  and  in  any  event  is  likely  to  be  earnest,  per- 
manent, and  as  generous  as  the  institution  deserves. 

Then  there  is  the  way  of  independent  subscriptions  taken  from  individuals  in- 
discriminately. This  is  the  least  desirable  and  the  most  hazardous  support  an 
institution  can  have.  The  fortunes  of  the  givers  may  change;  there  is  no  rallying 
ground  and  no  common  standards  upon  which  such  an  institution  can  be  operated, 
because  of  the  diversity  of  opinion  and  the  diversity  of  interests  of  the  givers; 
so  that  it  may  well  come  to  pass  that  a  large  giver  to  such  an  institution  may  be- 
come dissatisfied  with  the  policies  and  standards  upon  which  it  is  conducted,  and 
failing  to  change  these  to  suit  himself  his  subscriptions  may  be  withdrawn. 

For  the  support  of  Catholic  institutions,  the  clergy,  the  various  orders  of 
monks,  and  the  sisterhoods  can  appeal  to  contributors  from  the  religious  side. 
These  religious  orders  have  their  ideals  and  their  institutions  will  be  conducted  in 
step  with  these  ideals,  so  that  there  is  something  very  definite  upon  which  the 
institution  can  be  founded,  and  whatever  the  weaknesses  may  be  in  such  hospitals 
there  will  be  no  contending  factions,  only  one  set  of  morals,  one  set  of  ideals,  and 
the  institution  will  be  maintained  along  one  single  rigid  line  of  conduct.  Not 
always  are  these  holy  people  broad-minded.  They  have  few  opportunities  to  see 
life  in  its  broadest  side.     But  their  economies  will  be  great  and  their  humanities 


FINANCING    THE    HOSPITAL  _':i 

greater,  and  if  the  question  of  financial  support  must  come  to  a  test,  as  between 
these  orders  and  any  other  form  of  support,  the  Catholic  hospital  will  be  operated 
and  maintained  more  economically  than  any  other,  not  only  because  of  the  single- 

Handedness  of  the  moving  spirits,  but  also  because  many  of  these  religious 
people  give  their  service  for  the  glory  of  God  and  without  salaries.  These 
Catholic  hospitals  are  an  illustration  of  the  support  of  the  hospital  from  the 
religious  side. 

Another  illuminating  example  of  support  based  upon  the  religious  impulse  is 
the  maintenance  of  a  great  number  of  organized  charities  in  the  country  by  the 
Jewish  people,  the  most  characteristic  of  which,  perhaps,  are  those  of  the  Associated 
Jewish  ( 'harities  of  Chicago.  This  organization  is  composed  of  some  four  thousand 
of  the  Jewish  people  of  the  city  who  have  arrived  at  that  stage  of  financial  inde- 
pendence that  will  permit  them  the  privilege  of  contributing  money  for  purposes 
other  than  their  own  living.  They  give  §5  a  year  or  85000,  according  to  their 
ability.  This  money  is  placed  in  a  common  fund  for  the  support  of  a  large 
number  of  charities.  These  charities  have  been  initiated  at  different  times  through 
large  gifts  of  individuals,  perhaps,  and,  after  having  been  operated  in  a  small  way 
by  such  individual  support,  they  have  been  thereupon  taken  over  by  the  Associated 
Jewish  Charities  and  have  been  supported  out  of  this  common  fund.  In  this  way 
the  Jewish  people  of  Chicago  are  maintaining  a  hospital  of  four  hundred  beds,  con- 
ducted along  modern  lines;  a  home  for  orphans,  a  home  for  the  friendless,  a  home  for 
the  aged,  a  bureau  to  provide  for  the  temporary  relief  of  those  who  need  it,  a  per- 
sonal service  institution  to  compel  negligent  heads  of  families  to  support  those 
dependent  upon  them,  that  takes  care  of  helpless  and  unfortunate  girls,  and  the 
like;  a  dispensary  in  the  center  of  the  poor  section  of  the  city  that  ministers  to 
some  sixty  thousand  patients  per  year;  a  milk  station  in  the  heart  of  the  poor 
section,  which  provides  pure  milk  for  the  sick  and  for  the  babies  of  the  poor,  either 
entirely  free  or  at  actual  cost. 

This  central  organization  maintains  a  general  watchfulness  over  all  its  insti- 
tutions— insists  upon  economy  and  efficiency  in  their  administration.  Each 
institution  is  conducted  by  its  own  board  of  directors,  and  these  are  answerable 
at  the  end  of  each  year  to  the  central  organization  for  their  stewardship.  At  the 
end  of  each  month  the  deficits  of  all  the  institutions  are  made  up  by  check  from  the 
central  body,  so  that  in  an  existence  of  forty  years  or  more  not  a  single  one  of  the 
Jewish  institutions  of  Chicago  has  ever  owed  a  dollar  for  more  than  thirty  days. 
This  method  of  financing  makes  for  economy  in  the  purchase  of  supplies  and  for 
business  principles  in  the  administrative  forces  of  the  institutions,  and  while  the 
central  Jewish  body  is  most  liberal  toward  the  boards  of  directors  of  its  subsidiary 
organizations,  it  is  equally  exacting  in  the  matter  of  correct  financial  methods  in  the 
institutions  working  under  it. 

There  is  a  lesson  for  all  in  the  results  that  this  great  Jewish  body  in  Chicago 
has  attained.  At  the  present  time  the  subscription  list  aggregates  (465,000  per 
annum,  and  it  is  a  comparatively  easy  matter  for  the  leaders  of  the  Associated 
Charities  to  increase  this  amount  at  any  time  that  added  funds  may  be  needed, 
because  all  these  charities  are  so  conducted  that  every  subscriber  has  come  to  take 
a  personal  interest  and  a  personal  pride  in  their  achievements  and  the  amount  of 
good  they  do.  The  broad  lesson  to  be  learned  is  this,  that  there  are  enough  char- 
itably disposed  people  in  nearly  every  community  to  provide  for  the  needs  of  that 
community.  It  is  only  essential  to  inspire  confidence  in  the  earnestness  and 
intensity  of  effort  in  the  conduct  of  the  institutions  to  secure  adequate  support 
for  whatever  institutions  are  required. 


24  INTRODUCTION 

Of  course,  there  are  drawbacks  and  hazards  in  this  form  of  support,  and  there 
are  dangers  threatening  this  kind  of  organized  charity.  In  the  first  place  there  are 
many  people  who  have  very  decided  views  as  to  the  direction  they  want  their 
charity  to  assume.  One  person  may  be  attracted  toward  a  children's  charity; 
another  may  wish  his  or  her  money  to  be  expended  in  the  care  of  a  maternity 
hospital,  while  still  another  will  prefer,  for  sentimental  reasons,  to  give  for  the  benefit 
of  orphans,  or  for  unfortunate  girls,  or  for  some  other  very  special  purpose.  To 
these  classes  a  great,  all-embracing  charity  will  not  particularly  appeal,  and  it  may 
not  satisfy  them  at  all.  To  this  extent  such  an  association  will  fail  to  attract  some 
support  that  would  be  well  worth  having. 

Then,  also,  there  is  danger  of  overloading  such  an  association.  One  or  a  few 
very  active  and  philanthropic  persons  may  inaugurate  some  special  charity,  run 
it  at  their  own  expense  for  a  time,  then  undertake  to  load  it  on  the  association. 
The  charity  itself  may  be  a  most  worthy  one,  but  may  prove  the  proverbial-  straw 
to  overload  the  association;  and  in  any  event  it  will  open  the  way  to  similar  demands 
and  make  a  precedent  not  easily  brought  to  a  check  when  necessary. 

But  to  the  author's  mind  there  is  another  factor  in  this  association  form  of 
charity  that  ought  to  be  reckoned  with  at  the  very  outset.  Naturally,  the  organizers 
of  such  an  association  will  want  to  look  a  long  way  ahead  for  breakers,  and  to  discern 
the  clear  sailing  waters  of  permanency  and  safety.  They  will  most  likely  want 
to  provide  against  a  rainy  day,  if  the  metaphor  may  be  changed,  by  influencing  the 
gifts  of  large  funds  by  way  of  bequests  and  legacy.  Shall  such  gifts  be  made  to  the 
individual  charities  or  to  the  association?  Are  association  officers  warranted 
in  asking  the  subsidiary  charities  to  pool  their  gifts  into  the  common  fund  without 
any  conditions  of  reversion,  or  may  each  charity  accept  whatever  is  offered,  the 
interest  to  be  used  for  the  institution's  benefit,  and  the  principal  to  be  controlled 
by  its  own  board?  And  will  such  pooling  serve  eventually  to  rob  the  individual 
charities  of  their  sentiment,  and  take  away  that  personal  thing  so  necessary  if  a 
board  of  directors  is  to  do  the  greatest  amount  of  good  to  a  chosen  class?  It 
looks  to  the  author  like  such  an  association  could  well  become  so  big  eventually  that 
it  could  afford  to  devote  its  funds  toward  the  prevention  of  poverty,  or  at  least 
pauperism,  by  inaugurating  works  that  would  tend  to  take  the  beneficiaries  out 
of  the  pauper  class  and  place  them  in  the  class  of  self-supporters.  In  such  a  case 
the  charity  would  have  ended  and  a  business  regime  would  have  begun.  Again, 
the  association  officers  or  trustees  might  grow  cold  toward  certain  charities  very 
dear  to  the  hearts  of  those  who  had  given  money  for  their  permanent  support. 

If  the  association  were  established  in  a  policy  which  did  not  permit  it  to  accept 
other  than  annual  subscriptions,  and  if  the  individual  charities  were  put  on  their 
mettle  to  acquire  permanent  endowments  to  make  them  as  nearly  self-supporting 
as  possible,  there  would  be  much  nearer  a  survival  of  the  fittest  in  the  stretch  of 
years,  and  it  would  seem  to  be  a  better  arrangement  all  round. 

Additional  Support  of  Quasi-public  Institutions. — We  have  now  discussed,  at 
least,  the  more  desirable  forms  of  primary  support  for  these  community  institu- 
tions. There  are  oftentimes  very  material  resources  from  one  direction  or  another 
that  will  serve  to  make  up  any  deficiency  with  which  they  may  be  threatened  or 
that  they  may  actually  face.  Perhaps  one  of  the  surest  of  these  is  a  form  of  state 
aid  of  recent  birth,  especially  in  some  of  the  eastern  states.  This  support 
takes  the  form  of  a  per  capita  allowance  to  the  various  recognized  hospitals  and 
asylums  for  all  patients  cared  for,  who  would  otherwise  be  direct  charges  on  the 
public  and  who  would  have  to  be  cared  for  in  state  or  county  or  municipal  insti- 
tutions.    Like  most  new  efforts,  this  plan  has  not  yet  assumed  the  best  attainable 


FINANCING    THE    HOSPITAL  25 

form  and  lias  met  with  abuses,  as,  for  instance,  in  one  of  the  stales,  institutions  that 
arc  fortunate  in  their  political  affiliations  arc  granted  lump  sums  in  the  state's 
annual  appropriations,  irrespective  of  the  actual  number  of  patients  cared  for  in 
them.  Undoubtedly  the  per  capita  allowance  system  of  auxiliary  support  will, 
in  the  near  future,  become  count ry-wide  and  will  settle  down  in  its  details  to  a 
rational  and  equitable  basis. 

This  system  is  in  vogue  in  a  few  of  the  cities  of  this  country,  and  it  seems  to 
operate  about  in  the  same  way  as  state  aid.  In  Canada  there  is  a  disposition  to 
enlarge  upon  this  idea,  and  to  encourage  the  building  of  quasi-public  institutions 
by  private  charity.  In  a  few  places,  notably  Winnipeg,  the  city  authorities  have 
entered  into  contract  with  the  hospital  for  the  care  of  pauper  patients  to  an  agreed 
extent  and  at  definite  rates  extending  over  fixed  periods  of  time,  thus  insuring  the 
institution  against  a  burden  greater  than  it  can  bear. 

In  some  sections  of  the  country  the  so-called  "Saturday  and  Sunday  collec- 
tions" make  up  a  very  consequential  fund  to  be  divided  among  certain  institu- 
tions. Too  often  these  collections  are  committed  to  the  discretion  of  persons  who 
favor  certain  institutions,  and  thus  the  funds  are  not  always  divided  upon  as 
just  a  basis  as  could  be  desired,  but  that,  too,  will  be  cured  in  time. 

The  so-called  "Tag  Day"  innovation  is  in  the  same  class,  but  this  has  already 
won  for  itself  the  general  opprobrium  of  the  public  because  it  has  been  allowed  to 
fall  to  the  level  of  the  now  obsolete  strawberry  festival,  where  one  had  to  run  the 
gauntlet  of  women  who  knew  no  limit  to  their  insistence  and  who  excused  themselves 
for  indecent  solicitation  on  the  score  that  it  was  "in  a  good  cause." 

And,  then,  there  are  the  individual  gifts  to  institutions — outright  donations 
by  the  living  and  bequests  in  the  wills  of  the  dead.  While  such  gifts  are  uncertain 
and  never  to  be  counted  on,  there  are  certain  peculiar  features  attached  to  them 
to  which  allusion  ought  to  be  made.  In  years  gone  by  it  was  the  custom  for  the 
people  able  to  give  to  make  their  occasional  donations,  large  or  small,  to  the  insti- 
tutions appended  to  their  churches  or  their  favorite  societies,  and  donors  were 
not,  as  a  rule,  very  exacting  in  their  demands  as  to  how  their  money  was  to  be 
employed.  This  indifference  is  very  rapidly  giving  way,  perhaps  as  a  part  of  our 
more  accurate  commercial  sense,  to  a  demand  for  detailed  reports  of  stewardship. 
This  means  that  in  the  future  donations  of  this  individual  sort,  in  order  to  be 
received,  must  be  deserved.  It  will  not  do  any  longer  to  present  to  a  prospective 
giver  a  pamphlet  of  an  institution  containing  a  few  glittering  generalities  and 
much  self-praise.  If  the  annual  report  of  the  institution  sets  out  that  the  per 
capita  cost  of  caring  for  patients  during  the  past  year  was  $2,  the  prospective 
giver  will  want  to  know  what  became  of  that  S2;  it  will  be  no  answer  to  say 
that  this  S2  was  50  cents  less  than  the  amount  expended  per  capita  in  some 
other  institution.  Details  are  wanted:  Have  the  patients  been  properly  housed  in 
sanitary,  well-ventilated,  and  clean  rooms  and  wards?  Have  they  had  the  benefits 
of  modern  medical  and  surgical  appliances  in  the  treatment  of  their  diseases? 
Was  there  an  adequate  dietetic  competently  carried  out  under  the  orders  of  medical 
men  well  versed  in  the  laws  of  metabolism,  nutrition,  waste?  Did  tin-  surgical 
patients  have  the  advantages  of  modern  asepsis  in  the  operating-  and  dressing-rooms 
and  in  the  details  that  go  to  make  these  rooms  efficient?  Did  they  have  the 
benefits  of  modern  .r-ray  appliances  and  electrical  apparatus?  What  about 
their  pathology  as  aitl  to  the  diagnosis  of  disease — the  urinology,  bacteriology, 
surgical  pathology,  serum  and  vaccine  therapy?  No  institution  should  be  per- 
mitted to  exist  in  this  modern  day  of  science  unless  its  administrators  have  at  least 
shown  an  appreciation  of  these  scientific  necessities  of  the  time. 


26  INTRODUCTION' 

Such  demands  as  these,  if  insisted  upon,  may  seem  exacting  and  even  cruel, 
but  would  it  not  be  better  to  have  fewer  institutions,  and  larger  and  better  ones, 
that  can  make  a  wiser  use  of  philanthropic  funds  for  the  adequate  scientific  care 
and  cure  of  sick  people,  than  to  have  many  and  irregular  and  inefficient  hospitals 
and  asylums?  Many  years  ago — and  not  so  very  many  years  ago,  either — good 
hospital  care  would  be  satisfied  with  a  clean  bed  in  a  clean  ward,  practical  but 
untrained  nursing,  a  good  doctor  to  prescribe  plenty  of  medicine.  This  descrip- 
tion will  not  satisfy  for  an  up-to-date  modern  hospital. 

Additional  Support  from  Special  Charges. — It  is  unfortunate,  but  true,  that  in 
most  quasi-public  hospitals  and  similar  institutions  the  administrators  rely  for  a 
considerable  proportion  of  their  support  on  special  charges  against  patients  in  the 
institution.  The  insistence  that  there  ought  not  to  be  any  special  charges  of  any 
kind  against  any  class  of  patients  in  any  institution  will  be  strongly  criticized.  And 
yet  let  us  see  if  this  position  is  not  well  taken:  When  we  accept  a  patient  in  a  hos- 
pital or  sanitarium  or  asylum  or  in  any  institution  where  a  cure  is  to  be  attempted, 
the  patient  comes  to  the  institution  with  at  least  an  implied  guarantee  that  he  will 
get  the  best  the  institution  has  to  give.  If  he  is  a  pay  patient,  we  have  accepted 
his  money  on  those  cerms,  no  matter  how  much  or  how  little  he  pays.  If  he  is  a 
free  patient,  we  have  accepted  funds  from  some  source,  and  in  accepting  those 
funds  have  guaranteed,  at  least  by  inference,  to  give  patients  the  best  attention 
of  which  modern  science  and  modern  humanity  are  capable.  If  we  withhold 
from  him  the  service  of  the  laboratory  of  pathology  to  aid  his  doctor  in  the  diag- 
nosis of  his  disease,  because  he  cannot  pay  for  such  service,  we  have  been  guilty 
of  gross  deception  to  that  patient  or  to  the  donors  of  the  funds  supposed  to  have 
been  given  for  his  care.  If  we  decline  to  take  an  x-ray  picture  of  a  broken  bone 
because  the  patient  cannot  pay  for  it,  we  have  refused  him  one  of  the  most  necessary 
aids  to  his  cure.  If  we  have  failed  to  give  him  the  benefits  of  the  modern  laws  of 
dietetics,  as  expressed  in  his  food,  we  have  deprived  him  of  one  of  the  fundamental 
factors  in  modern  therapy. 

These  thoughts  may  be  construed  as  Utopian,  since  even  to-day  in  nearly  every 
quasi-public  institution  in  this  country  extra  charges  are  made  for  these  services. 
But  they  will  not  remain  Utopian,  and  a  time  is  coming,  and  shortly,  when  the 
acceptance  of  a  patient  will  carry  with  it  an  obligation  to  furnish,  on  the  terms  of 
admission,  every  known  and  approved  scientific  aid  for  the  diagnosis  and  treatment 
of  the  disease  or  injury. 

But  while  such  charges  for  special  service  dominate  the  administration  of 
almost  every  institution,  we  shall  perhaps  have  to  recognize  them  and  bow  to  them 
until  a  better  day  comes;  and,  therefore,  we  shall  have  to  analyze  these  extra 
charges,  and  will  take  occasion  to  do  so  from  time  to  time  as  we  proceed,  under 
the  correct  headings ;  for  instance,  we  will  discuss  the  cost  of  feeding  free  patients 
as  against  the  cost  of  feeding  pay  patients;  we  shall  take  account  of  the  cost  of  pro- 
ducing x-ray  pictures  and  their  uses  and  limitations,  and  we  shall  discuss  the  cost 
of  various  forms  of  pathologic  work  as  they  come  up  in  order  under  the  general 
headings  of  pathology  in  hospitals. 

Classified  Hospital  Expenditures. — The  natural  sequence  of  thought,  if  we  are 
to  contemplate  the  establishment  of  a  public  or  semipublic  institution  in  a  com- 
munity, is  to  work  from  the  demand  toward  the  accomplishment;  that  is,  we  have 
the  demand  for  a  specific  institution,  and  we  have  now  to  look  somewhat  to 
satisfying  it,  the  kind  and  scope  of  the  institution  required,  and  we  have 
taken  the  measure  of  the  avenues  of  support  upon  which  we  may  count.  But 
we  have  not  yet  taken  into  account  the  amount  of  support  required,  nor  the 


FINANCING    THE    HOSPITAL  27 

various  channels  against  which  the  supporting  funds  must  be  charged.     Lei  us 
do  so  briefly. 

In  the  first  place  we  shall  have  to  build  the  structure.  In  our  sections  on 
Architecture  the  details  of  cost  will  be  given,  but  there  are  some  very  rough  figures 
that  may  be  profitably  used  just  now  to  give  us  at  least  some  idea  of  the  amount 
of  money  we  shall  have  to  use  immediately. 

Broadly  speaking,  hospital  architects  have  about  agreed  that  the  modern  hospi- 
tal building,  without  any  ornamentation  whatever  and  without  any  such  fittings 
as  plumbing  and  ventilation,  and  including  only  the  walls,  partitions,  floors,  doors, 
foundations,  and  roof,  all  of  them  built  of  the  average  material  under  average  con- 
ditions, is  about  twenty-five  cents  per  cubic  foot  of  space  occupied  by  the  building. 
The  additional  cost,  or  what  we  may  loosely  term  extras,  will  be  for  ornamentation, 
varying  greatly  in  amount,  depending  on  the  elaborateness  or  simplicity  of  the 
structure;  the  power  plant,  the  plumbing,  including  steam,  gas,  and  electric  fix- 
tures, and  whatever  of  artificial  ventilation  it  is  determined  to  employ. 

Let  us  take  for  instance  a  building  100  feet  long,  40  feet  wide,  and  six  stories 
of  12  feet  each  as  the  dimensions  of  the  building,  that  will  give  us  an  area  of  288,000 
cubic  feet  and  an  additional  40,000  which  we  must  add  for  a  ten-foot  basement, 
or  a  total  of  328,000  cubic  feet.  At  twenty-five  cents  per  cubic  foot,  the  cost  of 
such  a  structure,  wholly  bare  of  fittings  or  furnishings  or  ornamentation,  will  be 
$82,000.  The  fittings  for  such  a  building,  according  to  figures  allowed  by  the 
average  hospital  architect,  and  providing  for  the  very  best  of  plumbing,  carried  in 
runways  in  the  walls  according  to  the  latest  approved  plan  of  plumbing  installa- 
tion, will  cost  $30,000.  This  will  include,  however,  the  necessary  installation  of 
steam  pipes  to  carry  live  steam  for  sterilization  in  the  operating,  dressing,  serving, 
and  sterilization  rooms,  and  this  will  also  include  the  necessary  electric  installa- 
tion for  light  and  power  and  a  sufficient  amount  of  gas-piping  to  duplicate  the 
lighting  plant. 

Artificial  ventilation  is  as  yet  so  uncertain  and  unsatisfactory  that  it  may 
well  be  considered  wholly  experimental,  and  while  it  may  be  a  question  of  indi- 
vidual judgment  as  to  whether  such  a  plant  should  be  installed  in  the  present 
state  of  the  art,  there  is  no  question  that  provision  in  the  walls  should  be  made  for 
it  against  that  day  when  some  satisfactory  ventilation  scheme  shall  be  offered  by 
inventors.  There  are  a  number  of  kinds  of  runways  installed  to  carry  fresh  and 
tempered  air  into  various  parts  of  the  hospital,  that  which  seems  to  meet  with 
present  favor  being  galvanized  iron  runways  in  the  walls,  varying  in  size  accord- 
ing to  the  area  to  be  aired  and  tempered.  We  will  discuss  this  question  of  arti- 
ficial ventilation  very  much  more  in  detail,  and  perhaps  more  dogmatically,  under 
that  heading  in  the  sections  on  Architecture,  including  an  estimate  of  the  cost  of 
such  installation.  The  only  other  permanent  fitting  in  the  hospital,  the  cost  of 
which  ought  to  be  included  in  the  architectural  estimates,  is  the  vacuum-cleaning 
system,  and  this  also  we  have  gone  into  more  in  detail  under  the  sections  on 
Equipment. 

When  we  have  taken  all  these  items  of  expenditure  into  account,  we  may  be 
able  to  pretty  accurately  determine  the  cost  of  the  building  we  are  to  erect,  exclu- 
sive, of  course,  of  the  item  of  ground  for  the  institution,  which  will  vary  so  greatly 
both  in  quantity  of  land  and  price  as  to  prohibit  any  further  discussion,  and  also 
exclusive  of  whatever  extraordinary  ornamentation  may  be  designed. 

It  will  be  noted  that  no  attempt  has  been  made  in  this  section  to  estimate  the 
cost  of  the  construction  of  the  building  on  a  basis  of  the  number  of  beds  to  be 
installed.     Some  expert  writers  on  these  costs  will  insist  that  the  only  proper  com- 


28  INTRODUCTION 

putation  of  cost  is  per  bed,  and  the  figures  given  will  run  from  $1200  to  $2500 
per  bed.  It  may  be  seriously  doubted  whether  such  figures  are  really  helpful. 
The  question  will  come  as  to  the  proportion  of  space  in  the  institution  designed 
to  be  actually  occupied  by  patients,  and  the  other  space  that  we  might  call  ad- 
ministrative in  character,  such  as  offices,  reception  rooms,  kitchens,  dining  rooms, 
serving  rooms,  storage  space,  and  the  like. 

The  equipment  of  the  new  building  for  operating  purposes  contemplates  so 
nearly  the  whole  question  of  hospital  or  institution  management  that  we  shall  have 
to  dismiss  this  part  of  the  subject  from  our  thought  at  this  time,  referring  the 
reader  to  the  section  on  Equipment  of  the  General  Hospital  as  an  aid  to  the 
furnishing  of  whatever  kind  of  institution  he  is  interested  in ;  and  we  come  now  to 
that  peculiarly  elastic  subject  of  "running  expenses." 

RUNNING  EXPENSES 

In  the  term  "running  expenses"  we  must  include  every  item  of  cost  of  opera- 
ting the  institution,  including  the  interest  on  building  funds. 

Necessarily  any  figures  touching  upon  operating  expenses  must  be  extremely 
elastic,  and  in  a  work  such  as  this  is  designed  to  be  these  figures  must  safely  cover 
the  expenses  incident  to  running  an  elaborately  planned  institution,  that  is,  one 
in  which  it  is  designed  to  give  patients  the  very  highest  order  of  scientific  service 
of  every  character.  The  figures  herein  set  down  must  not  be  harshly  criticized 
if  they  are  greatly  in  excess  of  those  shown  in  the  annual  reports  of  average  insti- 
tutions in  this  country.  It  is  not  intended  to  advocate  in  this  work  average  insti- 
tutions or  institutions  conducted  upon  the  average  scale.  This  work  has  in  con- 
templation throughout  the  best  sort  of  institutions  known  to  modern  science. 
For  instance,  some  city  and  county  hospital,  poorhouse,  and  asylum  administra- 
tors point  with  pride  to  their  low  cost  of  feeding  patients;  one  large  general  hos- 
pital, conducted  by  one  of  the  first  cities  in  this  country,  might  be  cited  as  an  ex- 
ample; its  annual  reports  cite  the  fact  that  it  is  operated  for  less  than  $1  per 
day  per  patient.  And  yet,  turning  a  few  pages  of  this  annual  report,  one  finds 
that  there  are  thirty-six  nurses  to  care  for  a  few  short  of  six  hundred  patients,  and 
that  the  pathologic  work  is  performed  by  one  intern,  who  also  has  other  duties; 
and,  still  further,  that  the  raw  food  for  patients,  employees,  nurses,  and  interns 
averages  nineteen  cents  per  day  per  capita.  Instead  of  a  record  of  laudable 
achievement,  may  not  such  a  report  be  regarded  as  disgraceful  and  a  scandal  upon 
twentieth  century  civilization?  There  are  no  figures  to  be  offered  for  such  conduct 
of  an  institution,  and  no  figures  to  be  offered  to  those  who  would  follow  such  a 
lead.  It  is  pleasanter  and  will  be  more  profitable  to  describe  a  rational  regime,  in 
accordance  with  the  laws  of  living  as  they  are  to-day  and  along  the  lines  of  the  sci- 
entific possibilities  of  the  time. 

The  intimation  above  that  the  pro  rata  cost  will  be  about  the  same  whether 
the  institution  be  a  hospital  of  fifty  or  five  hundred  beds  will  have  been  noted  by 
the  reader.  This  will  bear  a  momentary  pause  for  contemplation.  The  state- 
ment was  not  made  without  due  reflection.  It  is  true  that  in  a  large  institution 
purchase  prices  will  be  lower;  the  hospital  that  can  buy  half  a  million  yards  of  gauze 
at  a  time  will  undoubtedly  obtain  these  goods  at  a  lower  price  than  the  one  per- 
mitted to  buy  only  fifty  thousand  yards;  and  food  purchased  in  large  quantities 
will  be  likewise  lower;  and  it  might  be  that  heads  of  departments  could  manage 
a  large  number  of  people  quite  as  well  as  a  small  number,  as,  for  instance,  a  head 
janitor  could  superintend  the  operations  of  fifty  floor  men,  wall  washers,  window 


Ki  NNING    EXPENSES  29 

cleaners,  and  the  like  quite  as  well  as  he  could  direct  the  operations  of  eight  <>r  ten 
people;  and  if  the  salary  of  this  head  janitor  be  divided  pro  rata  between  five  hun- 
dred patients,  the  per  capita  would  be  extremely  small.  And  this  same  logic  will 
run  throughout  the  hospital. 

Bui  I  here  are  offsets  and  counterbalances  to  these  items  of  saving  in  a  large 
institution,  which  may  well  he  construed  to  go  quite  to  the  extent  of  complete 
cancellation.  For  instance,  if  there  are  only  ten  men  workers  in  the  institution, 
they  will  not  need  a  head  janitor  to  direct  their  work;  it  can  be  done  by  the  matron 
or  housekeeper  of  a  small  institution,  or  by  the  superintendent  of  the  training- 
school.  If  there  he  a  considerable  saving  in  the  price  of  gauze  purchased  in  the 
larger  lot  as  against  the  smaller,  the  waste  in  the  use  of  gauze  in  a  large  institution 
will  almost,  if  nut  quite,  offset  the  difference  in  price  as  against  the  economics 
and  care  and  watchfulness  that  can  be  practised  in  the  smaller  hospital,  and  the 
same  may  lie  said  also  of  the  purchase  of  food  supplies;  where  small  quantities  are 
purchased  for  a  small  number  of  people,  while  the  price  may  be  greater,  the  waste 
will  he  infinitely  less  in  the  small  hospital,  due  to  the  possibilities  of  the  same 
watchfulness  and  care  in  the  supervision  by  some  responsible  head.  And  so  things 
will  go  clear  through  the  institution;  economies  in  purchase  practicable  in  the 
larger  one  will  be  oftentimes  more  than  counterbalanced  by  the  economies  in  the 
use  of  consumable  things  in  the  smaller  institution.  Take,  for  instance,  as  one 
more  illustration,  the  difference  in  salary  between  the  two  superintendents  in  these 
two  institutions  under  discussion.  The  small  institution  will  pay  its  superintend- 
ent SI 200  per  year.  He  may  be  an  untrained  layman  or  even  a  fairly  good 
physician;  if  a  layman,  he  may  be  well  versed  in  the  accounting  department  of  such 
an  institution  and  may  be  able  to  keep  his  books  in  good  order,  but  he  is  more  than 
likely  to  fall  far  short  in  his  ability  to  purchase  supplies;  and  if  he  should  happen 
to  be  an  expert  in  both  of  these  directions  it  is  highly  probable  that  his  talents 
do  not  go  so  far  as  to  equip  him  for  carefulness  in  the  husbanding  and  purchase 
of  medical  and  surgical  supplies.  If  the  superintendent  be  a  medical  man  he  may 
participate  in  that  proverbial  lack  of  business  directness  so  common  to  the  mem- 
bers of  the  medical  profession,  and  so  the  institution  loses  to  whatever  extent 
it  shall  fall  short  in  business  administration  of  its  affairs.  The  superintendent 
of  the  large  hospital  of  to-day  draws  a  salary  varying  anywhere  from  S5000  to 
$10,000  a  year,  and  it  is  highly  probable  that  the  $10,000  man  is  the  cheapest 
investment  his  institution  indulges  in;  and  without  any  question  he  will  not  only 
make  his  salary  a  non-essential  in  the  saving  that  he  will  be  able  to  practice,  bu1 
will  probably  be  able  to  save  many  times  his  salary  each  year,  so  that  again  the 
difference  in  the  expenditure  between  the  large  and  the  small  hospital  is  apparent 
rather  than  one  that  could  be  set  down  as  dominating  the  situation. 

Roughly  speaking,  the  modern  American  hospital  expends  about  $2.50  per 
day  per  patient.  There  are  many  institutions  that  are  run  more  economically 
than  this,  and  that  are  operated  fairly  well  at  an  expense  of  about  S2.00,  where 
certain  special  economics  are  practised  and  where  not  very  much  scientific  work 
is  clone,  but  it  may  be  said  the  average  will  run  about  $2.50,  and  these  expendi- 
tures can  be  distributed  or  classified  approximately  according  to  the  subjoined 
tabic,  although  exact  figures  can  never  be  had  in  such  classification:  for  the 
obvious  reason  that  one  institution  may  be  specially  fortunate  in  one  direction 
or  in  the  acquisition  of  one  class  of  supplies;  or  one  institution  may  exert  its 
activities  in  one  or  another  expensive  direction  or  cater  to  a  class  of  patients 
that  will  demand  some  specially  liberal  expenditure. 


30  INTRODUCTION 

PROVISIONS:  Cents.  PerCent. 

Raw  food — per  patient,  not  per  person $  .766  30.7 

Surgery  and  Dispensary  : 

Drugs  and  drug  sundries ] 

Appliances 

Instruments | 

Wines  and  liquors  and  alcohol }      .206 

x-Ray  supplies 

Laboratory  and  sundries 

Gauze,  cotton,  gas,  etc 

Domestic: 

Crockery 

Silver  and  glassware 

Kitchen  utensils 

Cleaning  supplies 

Hardware  and  brushes 

Fuel  and  light J.     .263  10.9 

Repairs  and  expenses 

Laundry  supplies 

Miscellaneous  hospital  supplies 

Bedding  and  linen 

Furniture  and  fixtures,  etc j 

Establishment  Charges: 

Insurance 1       m  _  _ 

Taxes,  etc I       °17  ■' 

Power  Plant: 

Fuel , ) 

Oil  and  waste \      .20  8.0 

Ice  plant,  etc J 

Rent 014  .6 

Salaries  and  Wages 913  36.6 

Miscellaneous  : 

Printing  and  stationery ^| 

Postage 

Advertising \      .053  2.1 

Telephone  and  telegraph I 

Sundries J 

Management: 

Incidentals — Auditing,  etc .064  2.6 

$2,496  100 

Let  not  the  prospective  hospital  builder  or  board  be  frightened  at  the  pres- 
entation of  figures  of  expenditure.  These  are  not  hard-and-fast  figures,  and  many 
economies  can  be  practised  to  lower  them  here  and  there  under  conditions  that 
exist  in  every  hospital.  For  some  institutions  the  raw  food  figures  might  per- 
haps be  higher,  although  that  is  not  likely,  and  in  some  places  they  will  be  materially 
lower.  The  question  of  hospital  help  will  be  subject  to  variation.  In  a  good  many 
places  convalescent  patients  can  be  pressed  into  service  to  perform  quite  a  con- 
siderable amount  of  the  unskilled  labor  of  the  institution.  In  asylums,  poor- 
houses,  orphanages,  and  even  in  some  general  hospitals  where  convalescents  are 
kept  until  well  advanced  in  convalescence,  there  will  be  practically  free  help 
available  to  grow  farm  products,  if  the  land  is  at  hand;  to  raise  poultry,  if  there  is 
an  expert  director  for  that  department  of  industry;  and  to  care  for  and  milk  the 
institution's  own  herd  of  cows,  if  it  be  practicable  for  the  institution  to  keep  a 
herd. 

Let  us  now  pause  for  a  moment  on  the  ground  we  have  just  covered,  in  order 
to  fix  in  the  mental  vision  some  essential  points  in  institution  organization,  construe- 


RUNNING   EXPENSES  31 

tion,  and  operation.  If  we  have  dwelt  upon  the  problem  of  a  new  institution  in  a 
new  community,  it  has  been  wholly  for  the  purpose  of  discussing  the  question  from 
its  inception  to  its  realization.  The  problem  will  hardly  come  in  a  new  shape  to 
most  of  us.  We  have  already  made  the  start;  we  have  a  hospital  or  sanitorium 
or  orphanage  already  in  operation;  it  has  grown  too  heavy  a  financial  load,  or  it 
seems  not  altogether  in  tone  with  the  greatest  local  need,  or  in  some  of  its  parts 
the  machinery  seems  not  to  work  well.  In  what  we  have  said  heretofore  in  this 
chapter  we  have  tried  to  present  some  basic  thoughts,  which,  while  they  may  not 
fit  the  special  case,  will,  at  least,  raise  some  doubts  about  present  methods  and  so 
move  toward  new  view-points ;  and,  finally,  in  the  mental  struggle  we  may  arrive 
at  a  successful  settlement  of  our  individual  problem,  whatever  it  may  be. 

We  have  started  out  with  the  conception  of  a  new  institution  in  the  mind  of 
perhaps  a  single  individual;  we  have  seen  the  idea  grow  until  it  became  a  commu- 
nity-wide problem;  we  have  attempted  to  give  it  direction  and  force,  to  supply  the 
details  as  to  the  kind,  character,  and  size  of  institution  needed;  to  offer  a  few  sug- 
gestions as  to  the  creation  of  a  strong  and  enduring  organization  behind  it;  to 
point  out  some  of  the  means  by  which  the  modern  institution  may  be  financed 
and  some  of  its  avenues  of  expenditure. 

The  pathway  we  have  trod  in  the  story  is  worn  hard  by  the  travel  of  many 
tired  feet;  the  ashes  of  old  camp-fires  are  everywhere  along  the  way,  where  those 
who  have  been  lost  in  the  mazes  have  stopped  to  rest  and  build  up  new  strength 
for  the  further  journey  over  the  rocks  and  through  the  woods  of  perplexity.  Our 
roadway  has  led  into  no  new  and  unexplored  country,  but  perhaps  some  of  us  by 
traveling  day  after  day  and  year  after  year  have  found  a  short  cut  here  and  there 
where  the  going  is  smoother  and  the  road  is  pleasanter. 

If  this  section  shall  have  added  a  single  new  thought,  or  led  to  one  new  idea, 
or  given  a  single  ray  of  light  to  one  fellow-traveler  whose  burden  is  heavy,  it  will 
not  have  been  written  in  vain. 


PART    I 


HOSPITAL    ARCHITECTURE 


FOREWORD 


The  following  work  was  written  to  place  the  various  kinds  of  building  mate- 
rials, devices,  and  arrangements  before  people  interested  in  the  building  and  man- 
agement of  hospitals,  so  that  prospective  builders  may  intelligently  select  the 
article  best  suited  to  their  needs,  the  local  conditions,  and  the  available  funds. 

The  writer  has  studied  materials  in  use  in  hospitals  for  upward  of  fifteen  years, 
and  the  statements  are  made  with  such  authority. 

It  is  not  a  treatise  on  the  architectural  art  or  the  science  of  construction,  but 
a  simple  exposition  of  the  ordinary,  also  latest,  practice  of  building  in  this  country 
for  hospital  purposes. 

The  planning  of  a  hospital  is  probably  more  difficult  than  the  planning  of  any 
other  kind  of  a  building  under  the  best  of  conditions,  that  is,  with  unlimited  land 
and  unlimited  funds;  but  when  the  site  and  the  funds  are  restricted  the  problem 
becomes  further  complicated  and  depends  so  much  on  the  surroundings,  the  method 
of  management,  and  its  intended  use  that  it  is  practically  impossible  to  lay  down 
rules  which  can  be  followed  and  which  will  fit  every  case. 

Few  architects  understand  that  there  is  a  great  difference  in  the  management 
of  hospitals,  and  that  which  is  considered  excellent  in  one  institution  may  be  held 
execrable  in  another.  In  consequence,  many  institutions  are  built  without  a  proper 
understanding  between  the  architect  and  the  management.  The  scheme  devised 
by  the  architect  may  operate  like  a  well-made  machine  in  the  hands  of  one  person, 
and  may  break  down  completely  in  the  hands  of  another  trained  in  an  institution 
having  a  totally  different  method  of  operation. 

This  argument  is  not  advanced  to  defend  all  of  the  architectural  mistakes,  but 
many  of  the  so-called  mistakes  are  thereby  explained.  In  too  many  instances  the 
management  looks  to  the  architect  as  a  person  of  unlimited  knowledge  of  all  the 
details  of  hospital  management,  and  pays  but  little  attention  to  his  sketches  and 
plans  when  they  are  submitted  in  the  formative  stage,  and  he,  in  turn,  hearing  no 
criticism,  believes  that  his  sketches  and  drawings  have  had  the  study  and  approval 
of  the  management  or  building  committee,  so  that  no  one  is  aware  of  the  short- 
comings in  the  building  until  it  has  progressed  so  far  that  the  damage  is  irre- 
coverable. 

Almost  every  architect  is  only  too  glad  to  have  an  intelligent  criticism  of  his 
preliminary  work,  for  a  piece  of  work  that  is  satisfactory  to  its  users  and  patients 
will  redound  to  the  credit  of  all  connected  with  it.  Tt  might  be  wished  that  super- 
intendents, matrons,  superintendents  of  nurses,  and  directors  appreciated  that  a 
failure  in  the  proper  working  out  of  a  plan  can  easily  be  avoided  if  they  would 
gather  their  views  into  a  sensible  co-ordinated  statement,  and  discuss  these  with 

3  33 


3-4  HOSPITAL   ARCHITECTURE 

the  architect  before  the  plans  have  advanced  to  a  point  where  it  would  mean  loss 
to  the  architect  if  he  had  to  begin  over  again,  and  discuss  the  various  points  with 
him,  each  patiently  listening  to  the  other's  criticism  or  reasons  why  any  arrange- 
ment under  discussion  will  not  permit  of  proper  or  economic  administration,  or  may 
not  be  good  planning,  and  thereby  arrive  at  a  mutually  satisfactory  arrangement. 

Naturally,  the  architect,  expert  and  learned  though  he  may  be  in  the  technic 
and  practice  of  his  own  profession,  cannot  be  expected  to  be  familiar  with  the 
details  of  the  work  of  the  hospital  superintendent,  housekeeper,  superintendent  of 
nurses,  and  the  various  departments  heads;  therefore,  he  must  rely  in  a  large  meas- 
ure upon  those  who  are  familiar  with  hospital  administration  for  suggestions  con- 
cerning the  utilitarian  purposes  of  the  building  to  be  erected. 

There  is  another  difficulty  just  here,  too,  in  that  very  few  hospital  workers 
seem  to  be  able  to  interpret  even  the  simplest  rough  sketches,  floor  plans,  eleva- 
tions, and  details.  The  result  is  that  they  are  inclined  to  attach  a  blanket  approval 
to  whatever  is  submitted  to  them,  and  then,  after  the  specifications  are  drawn  and 
even  after  contracts  are  let,  they  come  in  with  an  eleventh-hour  protest  against 
plans  that  already  have  received  the  unanimous  and  supposedly  intelligent  approval 
of  everybody  concerned.  All  this  means  that  the  architect  is  entitled  to  an  intel- 
ligent and  painstaking  study  of  his  plans  by  those  who  are  considered  worthy  of 
having  responsibility  placed  in  their  hands. 

THE  SITE 

The  situation  of  a  hospital  is  of  prime  importance,  and  the  existing  and  pos- 
sible future  surroundings  must  be  carefully  considered. 

Often  a  hospital  obtains  possession  of  a  piece  of  property  by  gift  or  bequest 
at  the  inception  of  the  enterprise,  or  an  existing  hospital  is  in  possession  of  a  piece 
of  property  when  the  time  for  an  important  increase  in  the  size  of  the  institution 
arrives.  The  piece  of  property  in  question  may  be  totally  unsuited  for  hospital 
purposes  and  should  be  abandoned,  and,  although  such  abandonment  may  be 
heroic  and  an  apparent  sacrifice,  the  loss  in  many  cases  will  be  only  temporary. 

Unsuitable  sites  hamper  the  growth  of  the  institution,  the  constant  increases 
or  changes  required  to  keep  step  with  the  progress  of  medicine,  or  an  impending 
change  in  the  neighborhood  from  a  residential  quarter  to  a  business  or  manufactur- 
ing quarter,  or  the  modifying  of  the  hospital  clientele  to  a  locality  situated  at  a 
greater  distance  from  the  hospital  may  make  such  a  site  undesirable  for  the  pur- 
pose. Generally,  the  difference  in  cost  between  a  new  site  and  the  selling  price 
of  the  unsuitable  site  is  small  and  a  very  small  percentage  of  the  total  investment. 

The  more  the  location  and  surroundings  of  a  hospital  approach  those  desirable 
for  a  high-class  residence,  so  much  more  will  the  site  be  desirable.  Ample  air, 
distance  from  neighboring  buildings,  distance  from  the  dust  of  the  streets,  and 
noises  caused  by  steam  railroads,  street  traffic,  electric  railways,  and  manufactur- 
ing plants  are  all  of  them  exceedingly  important  to  hospital  patients.  If  a  hospi- 
tal is  close  to  dusty  streets  the  dust  will  enter  the  building,  of  course,  through  open 
windows,  but  also  through  crevices  around  tight  windows.  The  ventilating  appa- 
ratus will  become  clogged  and  very  costly  in  point  of  constant  attention  to  keep  the 
air-washing  devices  in  the  perfect  operation  necessary  to  prevent  the  dust  from 
entering  the  ducts. 

Inasmuch  as  most  hospitals  must  be  maintained  within  the  limits  of  large 
cities,  close  to  their  activities,  they  must  be  built  on  restricted  ground  areas.  In 
such  cases  the  fresh  air  and  ventilating  devices  must  be  more  highly  organized 


THK   BITE  35 

and,  naturally,  more  expensive  to  install  and  operate.  On  account  of  the  rela- 
tively high  price  of  land,  city  hospitals  must  frequently  be  built  on  the  masse  or 
block  plan.  The  difficulty  with  this  is  to  arrange  the  building  in  such  a  manner 
that  every  room  will  receive  direct  sun-rays  during  some  time  of  the  day.  This 
is  practically  an  impossibility,  and  it  is,  therefore,  desirable  to  plan  so  thai  the 
wards  and  rooms  of  the  sick  will  receive  as  much  sunlight  as  possible.  The  auxil- 
iary rooms,  such  as  pantries,  chart  rooms,  and  linen  rooms,  are  then  placed  on  the 
north  side  of  the  building.  Many  of  the  hospitals  in  which  the  best  work  has  been 
done  in  this  country  are  built  on  such  plans;  but  where  a  semiblock  or  semipavil- 
ion  plan  is  possible  it  is  usually  more  desirable.  The  appearance  of  such  a  plan 
is  that  of  a  number  of  barrow  strips,  sometimes  joined  solidly  and  sometimes  by 
cut-offs  or  necks.  On  such  a  plan  all  of  the  wards  can  usually  be  arranged  to  receive 
direct  sun-rays  during  some  hours  of  the  day,  and  only  so  much  of  the  northerly 
side  of  the  building  is  arranged  into  patients'  living  space  as  may  be  absolutely 
necessary,  or  for  such  as  eye  wards,  where  sunlight  is  not  so  necessary. 

Sunlight  is  now  an  acknowledged  retardant,  if  not  an  actual  destroyer,  of 
micro-organisms,  and  it  is  highly  desirable  that  sunlight  shall  enter  almost  every 
part  of  an  institution. 

The  complete  pavilion  style  of  buildings  can  be  applied  but  very  seldom,  usu- 
ally only  for  public  institutions.  It  is  more  expensive  to  build  and  operate,  and, 
naturally,  more  elevators  and  more  attendants  are  required.  The  kitchen  ser- 
vice and  all  other  service  is  at  a  greater  distance  from  the  patients,  and,  especially 
in  inclement  climates,  covered  passageways  must  be  built,  and  usually  these  must 
be  two  stories  in  height — the  lower  one  for  pipes,  conduits,  and  kitchen  service; 
the  upper  one  for  patients,  visitors,  medical  attendants,  and  nurses. 

Such  passageways  are  of  a  high  first  cost;  their  maintenance,  heating,  and  light- 
ing also  must  be  taken  into  account.  Where  a  large  number  of  patients  must  be 
housed,  such  as  in  public  hospitals  of  large  cities,  counties,  and  states,  such  an 
arrangement  is  necessary  and  advisable. 

In  choosing  a  site  a  pleasant  prospect  from  the  wards  is  desirable  and  certainly 
a  benefit,  so  that  for  a  general  hospital,  an  elevation,  if  the  ground  is  rolling  or 
hilly,  is  more  desirable  than  lower  ground,  for  naturally  the  institution  will  be 
more  windswept,  and  an  airy  situation  is  highly  beneficial.  An  elevation  has  the 
further  advantage  of  good  natural  drainage.  The  basements  and  cellars  can  be 
drained  by  gravity  flow  of  sewage.  If  the  surrounding  ground  is  sandy  or  gravelly, 
and  the  drainage  is  of  adequate  size  and  at  a  sufficient  distance  below  the  lowest 
floor  level,  absolutely  dry  cellars  can  be  built,  and  a  certain  extent  of  cellar  is 
useful,  especially  in  connection  with  the  kitchen,  because  vegetables  and  some 
other  stores  can  be  bought  in  quantities  to  advantage  and  kept  in  good  condition 
until  required.  If  the  ground  is  sandy  or  gravelly  and  several  feet  above  the 
drains,  it  will  be  permissible  to  build  a  main  floor  directly  on  the  ground  without 
an  intervening  cellar  or  basement.  This  can  be  done  at  a  considerable  saving  in 
a  large  institution.  Several  hospitals  of  this  kind  with  a  first  floor  but  S  inches 
above  the  surrounding  grade  have  been  in  existence  for  a  number  of  years,  anil  are 
sanitary  and  otherwise  successful.  Inasmuch  as  the  bottom  of  foundations  must 
be  at  least  4  feet  below  the  surface  of  the  surrounding  ground  in  localities  having 
the  average  temperature  of  this  country,  not  much  is  gained  by  using  a  portion  of 
this  depth  as  a  cellar  or  basement  wall,  and,  further,  the  expense  of  excavating  the 
entire  site  of  the  building  and  removing  the  excavated  material  is  so  great  per  unit 
that  it  hardly  pays  to  create  ~o  much  cellar  or  basement  space  to  lie  used  only  for 
storage  and  the  passage  of  pipes.      The  existence  of  a  space  for  too  much  storage  is 


36  HOSPITAL    ARCHITECTURE 

often  a  detriment,  for  if  the  space  did  not  exist,  useless  plunder  would  be  destroyed 
or  sold  and  not  allowed  to  accumulate  to  gather  dust  and  become  dangerous  as  a 
fire  hazard  or  in  affecting  the  purity  of  the  air.  Large  and  useless  cellar  spaces, 
unless  carefully  built  and  maintained,  are  also  likely  to  become  foul  and  noisome. 
In  the  institutions  mentioned  previously,  where  the  first  floor  was  less  than  a 
foot  above  the  surrounding  ground,  every  square  foot  is  usefully  applied  to  the 
many  auxiliary  activities  of  the  hospital,  and  the  space  which  is  generally  created 
at  a  considerable  cost  and  used  only  for  storage  and  waste  space  is  converted  into 
valuable  space  by  the  additional  cost  of  finishing,  and  actually  one  story  is  gained. 

PLANNING  THE  HOSPITAL 

A  plan  should  be  laid  out  with  reasonably  straight  lines  to  permit  easy  obser- 
vation, good  illumination,  ventilation,  a  good  circulation  from  section  to  section, 
and  a  proper  interrelation  between  its  parts.  It  should  be  a  good  architectural 
composition  not  simply  to  be  one,  but  because  a  good  composition  will  afford  all 
such  desirable  qualities,  whereas  a  heterogeneous  jumble  of  rooms,  curved,  broken, 
and  contracting  and  expanding  corridors  will  defeat  and  prevent  the  desirable 
qualities,  making  administration  and  cleaning  difficult,  almost  impossible.  More- 
over, it  must  be  understood  that  straight  lines  and  rectilinears  are  stock  materials, 
and  any  deviation  from  these  adds  immeasurably  to  the  expense  of  a  building. 

Wide  corridors  are  attractive  in  appearance,  facilitate  communication,  and 
assure  good  ventilation,  for  they  provide  a  large  volume  of  air  when  windows  must 
be  kept  closed.  They  sometimes  impress  the  laymen  as  unnecessarily  costly,  but 
they  are  not,  for  they  are  the  least  expensive  part  of  the  structure;  one  foot  or  more 
added  to  the  width  adds  only  to  the  cost  of  floor  and  roof  construction,  and  not 
of  walls,  partitions,  equipment,  or  any  of  the  units,  such  as  doors  or  windows. 
When  reinforced  concrete  floors  are  continuous  from  outer  wall  to  outer  wall, 
over  the  two  corridor  walls  or  girders,  fairly  wide  corridors  actually  effect  an 
economy  in  the  amount  of  steel  and  concrete  in  the  floors  or  the  rooms  each  side 
of  the  corridors. 

Very  large  hospitals,  such  as  governmental  institutions,  will  usually  be  built 
with  separate  buildings  connected  only  by  tunnels  and  possibly  covered  walks 
on  the  roofs  of  same,  the  separate  buildings  obtaining  power  and  light  from  a  cen- 
tral station,  but  the  majority  of  hospitals  to  be  built  will  probably  house  less  than 
250  patients,  and  will  be  built  in  cities  where  they  should  be  fairly  close  to  the 
homes  of  patients,  and  will,  therefore,  be  built  where  land  values  are  compara- 
tively high,  which  will  result  in  restricted  dimensions,  and  this  does  not  permit 
of  spreading  the  buildings  over  acres  of  ground.  The  most  suitable  plans  for  such 
areas  are  the  semi-isolated  pavilion  type  of  the  block  plan,  which  can  be  combined 
in  a  variety  of  arrangements  and  some  of  which  are  shown  in  the  illustrations. 

Where  there  is  sufficient  land  area  to  make  it  possible  to  build  single  build- 
ings, that  is,  completely  isolated  pavilions,  this  should  be  done,  connected  by 
one-story  enclosed  corridors  for  service  piping,  and  used  during  inclement  weather, 
with  covered  open  passages  on  the  roof.  If  the  roof  is  sufficiently  low  and  over- 
hanging, there  can  be  no  objection  to  their  use  in  any  kind  of  weather. 

Wide  comiecting  corridors  provide  pleasant  open-air  porches  and  are  very 
convenient  to  the  connecting  pavilions,  and  if  the  pavilions  are  two  stories  high 
and  the  passages  the  same,  these  must  be  quite  ■wide  and  imposing  to  avoid  an 
ungainly  appearance.  Probably  20  feet  is  not  too  wide  and  does  not  add  much  to 
the  cost,  for  this  is  only  in  the  excavation,  floor  and  roof  construction,  the  cost  of 


PLANNING    THE   HOSPITAL  31 

the  side  \v:ills  remaining  the  same.  In  such  cases,  it  would,  however,  he  hesl  to 
arrange  for  the  fitting  of  casement  sash,  so  that  they  may  be  used  as  parlors  in 
stormy  weather. 

A  small  complete  hospital  contains  all  of  the  parts  which  a  unit  .,1'  a  large 
hospital  should  also  have,  and,  inasmuch  as  proper  administration  requires  the 
division  of  a  large  hospital  into  parts  or  units,  any  one  of  these  should  he  the  -ann- 
as the  ward  Moor  of  a  small  hospital.  In  a  small  as  well  as  in  a  large  hospital  one 
floor  of  any  unit  may  be  arranged  for  an  administration,  or  service,  or  nurses' 
teaching,  or  operating  department. 

Many  large  and  elaborately  illustrated  works  have  been  published  on  Conti- 
nental European  hospitals,  but  these  are  of  little  value  to  the  American  builder, 
for  the  foreign  builders  do  not  appear  to  consider  it  necessary  to  have  the  con- 
veniences and  accessories  to  the  wards  considered  so  essential  in  this  country,  nor 
do  they  have  many  private  rooms.  In  the  European  plans  often  one  bath  to  a 
III  km  appears  to  be  considered  sufficient,  whereas  in  this  country  very  many  patients 
demand  separate  rooms  and  private  baths. 

Whatever  private  rooms  they  have  are  usually  on  the  corridors  of  the  wards, 
where  the  patients  are  subjected  to  the  noise  of  communication  and  curiosity  of 
other  patients,  whereas  American  practice  endeavors  to  locate  the  private  rooms 
away  from  corridor  traffic,  to  make  them  as  quiet  and  give  them  as  much  privacy 
as  possible. 

American  designers  are  planning  hospitals  with  more  single,  two,  three,  or  four 
lied  wards,  and  with  fewer  large  wards.  This  may  increase  the  cost  of  nursing  and 
other  service,  but  it  assists  in  isolation  and  classification,  and,  considering  that 
many  more  people  capable  of  paying  at  least  part  rates  are  making  use  of  hospi- 
tals, the  additional  cost  is  thereby  balanced. 

A  building  for  convalescents  is  very  helpful  to  patients,  and  will  often  be  re- 
munerative to  the  hospital;  such  a  building  need  not  be  as  highly  detailed  or  as 
fully  equipped  as  the  hospital  building  proper,  for  the  convalescents  can  help  them- 
selves to  a  great  extent,  can  go  some  distance  to  their  meals,  so  that  a  much  cheaper 
grade  of  building  will  suffice. 

A  unit  in  proportion  to  the  size  of  the  proposed  hospital  should  be  designed 
and  one  of  these  incorporated  in  the  whole  plan  for  each  department,  such  as  male 
medical,  female  medical,  male  surgical,  female  surgical,  maternity,  private  rooms, 
etc.,  each  one  as  far  as  possible  self-contained  so  as  to  keep  the  nurse  close  to  her 
patients,  and  make  it  unnecessary  to  leave  the  unit  while  on  duty;  the  surgical 
units  should  have  a  surgical  dressing-room,  the  maternity  department,  a  nursery, 
labor  rooms,  and  accessories,  and  each  of  the  others  their  special  requirements. 

The  units  must  be  in  easy  communication  with  the  kitchen,  the  general  labora- 
tory, the  operating  department,  anil  other  common  divisions. 

A  unit  should  have  the  following  rooms: 

1.  The  ward  or  private  room. 

2.  Toilet  room. 

3.  Nurses'  toilet  room. 

4.  Serving  room  or  diet,  kitchen. 

5.  A  quiet  room  for  one  bed. 

6.  Bath-room. 

7.  Utility  or  sink  room. 

8.  Cabinet  for  linen. 

1).  Cabinet  for  medicine. 
10.  Station  for  nurses. 


38 


hospital  architecture 
Plan   of  Unit 


If  the  units  can  be  made  large  enough,  one  or  more  of  the  following  will  be  of 
advantage : 

11.  A  solarium. 

12.  A  reception  alcove  or  room. 

Where  two  or  more  units  are  close  together,  Nos.  3,  4,  5,  11,  and  12  may  some- 
times be  arranged  so  that  they  can  be  used  in  common. 


The  same  space  occupied  by  a  ward  can  be  divided  into  a  number  of  single- 
bed  or  private  wards,  or  into  half-pay  wards.  One  of  these  units  may  be  one- 
story  or  any  number  of  stories  in  height  to  increase  the  capacity. 


The  small  plans  (Figs.  1  and  2)  show  a  development  of  one  of  these  units  in 
the  simplest  form,  with  wards,  a  single  private  room,  a  quiet  room  for  emergency, 


PLANNING    TIIK    HOSI'ITAJ, 


39 


and  the  few  absolutely  necessary  administrative  offices;  toilet,  bath,  slop,  sink- 
room,  nurses'  retiring-room,  supply  room,  and  a  sun  porch  in  the  semicircle  at  the 

end. 

The  following  plana  illustrate  combinations  of  two,  three,  four,  and  more  units 
and  the  manner  in  which  they  are  customarily  assembled  to  obtain  different  capac- 


Fig.  o. — Various  combinations  of  units  assembled  in  various  ways  to  suit  varying  capacities  and 

conditions. 


ities,  and  huge  institutions  are  merely  modifications  of  these  arrangements,  to 
meet  particular  conditions,  special  sites,  or  individual  taste.  Under  the  chapter 
on  the  Architecture  of  the  Small  Hospital,  we  have  gone  somewhat  into  detail  con- 
cerning economies  in  space,  cost,  and  convenience,  but  the  units  themselves 
are  the  same. 


40  HOSPITAL   ARCHITECTURE 

Figure  3  shows  a  number  of  such  combinations,  assembled  in  the  various  shapes, 
because  of  the  lay  of  the  ground,  shape  of  the  lot,  or  the  taste  of  the  building 
board. 

THE  AREA  PER  PATIENT 

The  minimum  area  and  cubic  contents  per  bed  permitted  in  Chicago  at  the  close 
of  1912  are  80  square  feet  and  800  cubic  feet.  No  distinction  is  made  between 
adults,  children,  or  infants.  Such  factors  are  probably  based  on  usage  which 
appears  to  have  been  safe,  or  they  were  selected  to  accommodate  and  not  disturb 
existing  institutions. 

A  new  law  with  factors  for  adults,  children,  and  infants  will  be  submitted  to  the 
legislature  of  the  State  of  Illinois  in  the  coming  session.  A  similar  law  will  prob- 
ably be  enacted  for  the  State  of  Ohio.     The  factors  are  as  follows: 

Minimum  square  feet  of  floor  space  per  person: 

Adults.      Children".       Babies. 

Private  rooms 90  75  55 

Wards SO  65  45 

Minimum  cubic  feet  of  air-space  per  person: 

Adults.      Children.       Babies. 

Private  rooms 900  675  500 

Wards S00  600  400 

These  minimum  factors  are  low  and  permit  considerable  individual  discretion. 

The  placing  of  the  bed  and  the  floor  area  for  one-bed  wards  is  described  in  a 
later  section.  In  larger  wards  the  spacing  of  the  beds  depends  generally  upon  the 
architectural  spacing  of  the  windows,  and,  therefore,  in  a  measure,  governs  the 
floor  area  occupied  and  the  story  height.  A  few  dimensions  will  explain  the  various 
factors. 

Inasmuch  as  the  most  important  dimensions  of  the  areas  is  the  distance 
from  center  to  center  of  bed,  area  alone,  without  a  minimum  distance  from 
bed  to  bed,  does  not  result  in  a  sound  provision.  Eight  feet  from  center  to  center 
of  bed  is  fairly  liberal,  but  for  infectious  cases  this  dimension  should  be  greater. 
Where  beds  are  placed  on  both  sides  of  a  ward,  the  distance  between  the  ends  of  the 
beds  should  not  be  too  close  for  efficient  ward  work.  Eight  feet  appears  to  be  the 
minimum  for  this  dimension,  with  two  beds,  each  6  feet  6  inches  long,  and  the 
space  of  1  foot  6  inches  at  the  head  of  each  bed  will  result  in  a  ward  24  feet  wide, 
and  this  dimension  should  be  increased  if  clinics  with  large  numbers  of  students 
are  held  in  the  ward.  A  ward  24  feet  wide,  with  beds  8  feet  on  centers,  provides 
96  square  feet  per  bed.  If  the  stories  are  12  feet  high  the  cubic  contents  will  be 
1152  cubic  feet  per  bed.  Possibly  this  story  height  may  be  decreased  in  the  open 
country  under  careful  management  of  windows  and  transoms. 

ARRANGEMENT  OF  ADMINISTRATIVE  UNITS 

THE  ADMISSION  ROOMS 

Before  we  can  discuss  the  form  of  the  admission  rooms  in  an  institution,  we 
must  understand  first  just  what  work  is  to  be  done  there.  It  matters  little  whether 
it  be  a  hospital  for  the  insane,  a  special  institution,  a  small  hospital  in  a  sparsely 
settled  community,  or  a  large  general  hospital  in  a  metropolis,  the  work  in  the  ad- 
mission rooms  is  the  same,  and  that  ought  to  be  limited  to  the  examination  of 


ARRANGEMENT   OF   ADMINISTRATIVE    UNITS  41 

patients,  preliminary  to  their  acceptance  or  rejection;  out-patienl  and  dispensary 
operations  and  the  business  of  the  public  should  be  performed  at  some  other 

entrance,  and  if  there  can  lie  entrances  for  each  of  these  classes  of  business  30 
much  the  better.  Indeed,  if  visitors  to  patients  can  be  classified  according  to 
their  social  status,  the  ward  patients'  visitors  baving  one  entrance  and  private 
patients'  visitors  another,  the  visiting  system  will  lie  much  simplified,  because  in 
most  hospitals  ward  patients  cannot  have  visitors  as  frequently  or  as  long  as  those 
in  private  rooms  for  obvious  reasons;  and  yet  it  is  difficult  for  the  public  to  under- 
stand this,  and  embarrassing  situations  are  likely  to  arise  if  two  persons  enter  at 
the  same  time,  and  one  is  permitted  to  visit  the  sick  relative  and  the  other  is  re- 
fused. 

Naturally,  admission-rooms  in  a  charity  or  free  hospital  will  be  more  largely 
patronized  than  where  the  clientelle  is  made  up  exclusively  of  private  patients, 
because,  in  this  latter  case,  the  patients  will  have  been  examined  by  the  doctor 
at  home,  and  the  patient's  status  in  the  hospital  will  have  been  directed  by  the 
attending  physician,  and  will  not  be  subject  to  revision  by  admission  interns. 
So  that,  in  contemplating  a  large  elaborate  admission  department,  we  must  under- 
stand that  we  are  dealing  especially  with  institutions  that  receive  a  considerable 
number  of  free  patients,  or  at  least  those  whose  status  must  be  subjected  to  in- 
quiry before  they  can  be  admitted  or  rejected. 

Figure  4  gives  an  outline  of  a  suite  of  admission  rooms  for  a  general  hospital, 
and  this  arrangement  may  lie  elaborated  almost  indefinitely  or  contracted  to  meet 
the  needs  of  a  small  institution. 

There  are  two  classes  of  patients  that  pass  through  the  admission-rooms,  the 
ambulatory  cases  that  come  afoot,  or  in  some  vehicle  other  than  an  ambulance, 
and  the  ambulance  cases  that  come  on  a  stretcher.  The  curved  clotted  line  in  the 
illustration  shows  a  peaked  roof  for  the  entrance  to  the  department  along  the 
carriage  drive.  This  driveway  should  be  enclosed  at  all  hours,  because  patients 
entering  a  hospital  must  be  badly  frightened  at  best,  and  if  there  are  loungers 
and  curiosity  seekers  about  they  will  be  frightened  all  the  more. 

Let  us  follow  the  patient  who  comes  afoot,  applying  for  admission  to  the 
hospital.  He  passes  through  the  large  double-door  entrance,  turns  to  the  right 
into  the  common  waiting  rooms,  which  contain  seats  on  three  sides.  When  his 
turn  comes  to  be  examined,  he  passes  into  the  next,  or  examining  room,  where 
there  is  a  large  window  and  all  the  paraphernalia  for  making  preliminary  observa- 
tions. If  he  is  accepted,  he  is  taken  in  charge  by  an  attendant,  male  or  female, 
as  the  case  may  be,  and  passes  along  the  inner  corridor  into  the  bath-room,  where 
his  clothes  are  removed,  tied  into  a  bundle,  labeled,  and  thrown  into  the  chute. 
After  the  bath  he  is  given  hospital  clothing  from  the  closet  at  the  end  of  the  cor- 
ridor, and  passed  across  the  main  corridor  to  the  elevator,  which  takes  him  to 
his  destination  upstairs. 

In  the  event  that  the  admission  department  is  large  enough  to  justify  two 
examination-rooms,  the  second  room  shown  in  the  cut  may  be  used  and  the  patient 
passed  in  the  same  way. 

The  ambulance  patient  is  brought  on  the  stretcher  into  the  ambulance  dress- 
ing-room on  the  left  side  of  the  main  corridor.  Any  necessary  preliminary  dress- 
ing can  be  done,  such  as  blood  stopping,  and,  if  ihe  case  is  urgent,  the  patient 
may  be  placed  at  once  in  the  elevator  and  taken  to  bed  upstairs.  Sometimes  it 
is  necessary  for  the  patient  to  rest  following  a  dressing  or  examination,  and  for 
that  purpose  he  may  be  placed  on  a  couch  in  the  quiet  room  just  off  the  reception 
room.     At  times  it  is  impossible  to  give  the  patient  a  bath  and  change  the  cloth- 


42 


HOSPITAL   ARCHITECTURE 


ing,  as  a  preliminary  to  his  reception,  and  he  must  be  taken  upstairs  at  once. 
But,  again,  there  are  many  patients  who  come  to  a  hospital  in  an  ambulance  in 
such  a  filthy  condition  that  it  is  out  of  the  question  to  admit  them  to  the  clean 
hospital  wards  until  some  sort  of  effort  has  been  made  to  free  them  at  least  from 
the  vermin  with  which  they  are  infested,  and  for  that  purpose  there  is  a  bath- 
room, just  off  the  quiet  room,  where  these  patients  can  be  bathed  and  reclothed 
with  hospital  garments;  and,  as  with  the  other  class  of  patients,  the  clothing 


.  rvte.u  u  AN  C.  E 


A.  D  N*l  I  -5.5  t  O  N 


DE.PA.R.T  M  E  N  T- 


Fig.   4. 

can  be  done  up  in  bundles,  labeled  carefully,  and  thrown  into  the  chute.  The 
last  room  on  this  side  of  the  corridor  is  reserved  for  stretchers,  stores,  and  dressings 
In  smaller  institutions,  or  where  the  admission  department  is  of  small  im- 
portance, there  need  be  only  one  reception-room,  and  that  can  be  used  for  both 
classes  of  patients,  with  the  one  examining-room  off  it,  which  may  be  used  also 
for  a  quiet  room.  Under  such  conditions  there  can  be  one  bath,  one  clothes  closet, 
and  one  chute,  through  which  to  drop  the  patient's  clothing  to  the  sterilizing 
room,  and  thence  to  the  lockers  in  the  basement. 


ARRANGEMENT    OK    ADMINISTRATIVE    UNITS 


43 


ARRANGEMENT  OF   THE  LOCKER  AND  STERILIZING  ROOMS 

Figure  5  shows  a  locker  and  sterilizing  room  for  patients'  clothing  thai  can 
be  changed,  constricted,  or  elaborated  to  meet  any  size  of  institution.  It  will 
he  noted  that  there  is  an  elevator  coming  down  into  this  suite  which  can  lie  used 
to  convey  mattresses.  There  is  a  chute  also  for  the  handling  of  patients'  cloth- 
ing from  the  admission  rooms  above.  The  sterilizer  is  placed  conveniently  for 
the  placing  of  either  mattresses  or  clothing  at  one  end,  to  be  taken  out  the  other. 
The  mattresses,  after  sterilization,  are  taken  back  upstairs  by  way  of  the  elevator, 


v/);////////////;^,',.      '      ^    ^ 


JOR.TINO 


Fig.  5. 

which  is  not  ideal,  but  practicable,  and  the  clothing  can  be  placed  in  the  lockers 
marked  in  the  illustration. 

The  sorting  table,  with  bins  across  a  corridor  in  the  long  room,  may  be  arranged 
under  certain  conditions  for  the  handling  of  the  laundry,  and  especially  of  that  part 
of  it  that  should  be  sterilized  before  going  to  the  laundry  proper. 


THE  KITCHEN 

The  food  supply  of  an  institution  reaches  the  very  vitals  of  the  administration. 
More  will  depend  on  the  economy  and  system  of  the  arrangement  in  this  depart- 
ment than  in  any  or  all  of  the  other  departments  combined,  because  upon  that 
arrangement  and  system  will  depend  economics  in  the  care,  preparation,  and  serv- 
ing of  food,  and  upon  these  factors  will  depend  in  turn  the  costliness  or  the  econ- 
omy of  the  institution  management.  No  matter  whether  it  is  a  large  or  small  in- 
stitution, no  matter  whether  the  help  are  high-priced  paid  individuals,  or  largely 
recruited  from  convalescent  patients,  the  system,  or  want  of  system,  will  be  ever 
present  for  or  against  possible  economies  and  a  high  order  of  food  service.  If  it  is 
a  small  institution  of  very  limited  means,  the  more  reason  why  the  very  best  should 
be  got  out  of  every  dollar  expended  for  table  supplies.  If  it  is  a  large  and  wealthy 
institution,  the  food  will  be  served  better  for  the  application  of  proper  system, 
and  patients  will  get  more  for  whatever  money  is  expended,  so  that  the  kitchen 


44 


HOSPITAL   ARCHITECTURE 


arrangements   and  the  kitchen  auxiliaries  cannot  be  overestimated  in  import- 
ance. 

Of  course,  the  first  question  is  the  location  of  the  kitchen  and  the  location  of 
the  auxiliaries,  meaning  the  pantry,  refrigerators,  meat  shop,  pantry  for  prepar- 
ing vegetables  and  food  of  various  sorts,  closets,  scullery,  and  utensil  shelves. 


i^i^^j^T-^f^jiiiii 


W//////////M 


I 

1 


A.FCFC.A.NG-E.N'I 


Fig.  6. 


It  seems  to  be  the  fad  just  now  to  build  the  kitchen  at  the  top  of  the  house. 
Twenty  years  ago  it  would  have  been  well  to  have  the  kitchen  up  where  odors 
could  not  penetrate  to  the  balance  of  the  house.     We  had  practically  no  venti- 


ARRANGEMENT   OF    ADMINISTRATIVE   UNITS  I") 

Intion  in  those  days,  and  knew  almosl  nothing  about  taking  care  of  vapors  and 
odors.  We  do  know  something,  at  least,  aboul  taking  care  of  these  things  aow, 
and  the  same  imperative  reason  does  not  exist  for  having  the  kitchens  just  under 
the  roof.  An  immense  amount  of  carriage  is  required  to  and  from  the  kitchen. 
Many  trips  of  many  people  are  required  daily  and  hourly  to  and  fro,  especially  by 
people  from  the  outside,  and  mosl  of  us  object  to  tradespeople  and  all  the  non- 
descripts who  come  to  the  kitchen  for  various  purposes,  going  through  the  rest  of 
the  institution,  even  on  an  elevator;  they  stop  off  and  pry  where  they  have  qo 
business.  If  the  institution  is  a  large  one,  literally  tons  of  material  must  be  taken 
up  and  down,  and,  unless  one  has  paid  some  attention  to  the  immense  amount  of 
s- 1  ul!"  t  hat  reaches  the  kitchen  in  the  course  of  a  day,  one  will  not  be  able  to  compre- 
hend just  what  this  traffic  means.  Moreover,  the  top  of  the  house  is  perhaps  the 
most  desirable  part  of  the  house  for  institution  purposes,  and  the  basement  is  the 
least  desirable,  so  there  is  a  question  of  space  involved  also. 

Laws  of  sanitation,  and  in  many  places  the  law  of  the  locality,  prohibits  people 
living  in  the  basement,  even  the  help,  and  if  the  kitchen  is  on  the  top  floor  the  stores 
must  be  there  also,  so  that  the  basemen!  is  practically  vacant.  If  the  kitchen  is 
on  the  top  floor,  the  help  must  have  their  meals  on  the  top  floor,  and  more  valuable 
space  is  taken  up,  whereas  if  one  uses  the  basement  space  for  these  purposes  there 
is  economy  of  space;  it  may  be  safely  concluded,  therefore,  that  the  basement  is 
the  proper  place  for  the  kitchen  and  its  auxiliaries,  always  provided  that  it  is 
arranged  properly,  well  lighted,  ventilated  properly,  and  is  connected  conveniently 
for  the  transportation  of  food  to  various  parts  of  the  house.  Figure  6  is  a  diagram 
of  the  author's  conception  of  an  ideally  arranged  kitchen  with  its  auxiliaries. 
This  diagram  contemplates  a  basement  kitchen,  with  the  highest  possible  ceiling, 
20  feet  as  a  minimum,  30  feet  by  preference.  There  is  an  areaway  10  feet  wide  on 
each  side  of  the  kitchen;  the  windows  go  almost  to  the  ceiling,  and  the  window  glass 
is  in  three  independent  sash,  each  capable  of  being  raised  or  lowered  independent 
of  the  others,  for  purposes  of  light,  air,  and  additional  ventilation  as  required. 

ARRANGEMENT  OF  THE  MEDICAL  UNIT 
The  medical  ward  with  its  appurtenances  furnishes  all  the  ideals  of  what  we 
ordinarily  term  a  hospital  unit.  It  is  composed  of  a  ward  and  a  quiet  room  for 
patients,  and  the  things  that  lend  themselves  to  the  service  of  these  patients — 
linen-room,  serving-room  for  the  handling  of  food  for  the  ward,  a  convalescent 
dining-room  for  those  who  can  be  at  table,  slop-sink  room,  with  the  necessary 
sterilizers  and  sinks,  a  combination  bath  and  toilet-room,  or  two  separate  rooms 
for  these  two  separate  purposes,  and  one  or  more  quiet  rooms  in  which  to  care  for 
recently  operated  patients,  or  those  who  are  noisy  or  nervous,  or  for  those  who  are 
dying.  If  the  ward  is  to  be  kept  nice  and  clean,  and  free  from  mops  and  pails, 
then  there  should  be  a  porter's  room  or  janitor's  closet.  Figure  7  shows  what  the 
author  thinks  is  an  ideal  arrangement  for  such  a  suite  as  this  planned  upon  a 
somewhat  elaborate  scale.  Changes  may  be  needed  in  this  arrangement  to  meel 
certain  conditions;  for  instance,  the  isolation-rooms  might  have  to  be  away  from 
the  main  corridor  of  the  building,  because  of  the  noise  that  might  emanate  from 
them  and  extend  to  other  parts  elsewhere.  The  linen  and  slop-sink  room  should 
certainly  be  very  near  the  ward.  Perhaps  the  slop-sink  room  might  be  allowed 
to  change  places  with  the  bath  and  toilet  rooms,  so  that  these  latter  could  be  a 
little  bit  nearer  the  patients.  The  medicine  cabinet-  for  such  a  suite  as  this  can 
be  set  into  the  walls  of  the  corridor,  just  outside  the  ward,  or  at  some  point  in  the 
walls  of  the  ward  itself. 


46 


HOSPITAL    ARCHITECTURE 


The  serving-room  for  taking  care  of  the  food  is  properly  located  at  some  dis- 
tance from  those  offensive  rooms — the  bath,  toilet,  and  slop-sink  rooms — and  the 
convalescent  dining-room  is  properly  located  at  a  point  furthermost  from  the  ward, 
because  it  is  unnecessary  that  it  should  be  any  nearer. 


lZZ 


.   ■     r  . 


MEDICAL 


NiVAK-D 


A  K  R.ANG-E  ! 


Fig.  7. 


The  combination  of  double  swinging  doors  at  the  entrance  to  the  suite  are  for 
the  ingress  and  egress  of  patients,  either  to  or  from  the  suite,  into  and  out  of  the 
building.  In  this  arrangement  the  elevator  is  also  situated  at  the  end  of  a  small 
vestibule,  which  takes  away  a  great  amount  of  the  noise  normally  coming  from 
an  elevator. 


ARRANGEMENT  OF   ADMINISTRATIVE    UNITS  47 

THE  SURGICAL  WARD  UNIT 

The  surgical  ward  unit  may  be  arranged  precisely  as  the  foregoing,  excepting 
that  there  should  be  a  dressing-room  for  surgical  patients.  This  might  be  made 
in  the  same  space  by  constricting  somewhat  some  of  the  other  rooms,  or  one  of  the 
isolation  rooms  might  be  taken  for  the  purpose.  A  good  deal  of  the  dressings  jn 
such  a  surgical  ward  could  he  done  at  the  bedside,  by  the  use  of  a  dressing  call 
loaded  with  dressing  accessories. 

ARRANGEMENT  OF  THE  OPERATING  SUITE 

Before  we  discuss  the  ideal  operating-room,  or  suite,  we  must  understand  in 
a  general  way  what  is  to  be  done  there. 

Of  course  there  must  be  a  surgical  operating-room,  or  several  rooms,  as  the 
case  may  be,  and  as  we  shall  need  sterile  water,  and  as  the  instruments  must  be 
sterilized  immediately  before,  and  sometimes  during,  the  operation,  it  will  be 
necessary  to  have  the  sterilizing  room  nearby.  Supplies  are  constantly  called 
for.  and  therefore  there  must  be  a  supply  room  in  the  vicinity.  The  instru- 
ments must  be  taken  eare  of  properly  after  they  have  been  used  and  washed, 
and  there  must  be  a  case  for  them;  and,  if  the  institution  is  large  enough,  there 
should  be  a  room  kept  under  certain  physical  conditions  as  to  dryness.  There  is 
washing  of  every  sort,  soap  and  solutions  to  be  made,  utensils  to  be  boiled,  and 
all  these  things  make  it  necessary  that  there  should  be  a  wash-room  with  basins, 
sterilizers,  and  gas  plates.  Anesthetics  must  be  given,  and  it  is  becoming  more  and 
more  the  custom  to  give  the  anesthetic  in  another,  rather  than  the  operating- 
room,  because  of  the  mental  effect  on  the  patient;  therefore,  one  or  more  anesthetic 
rooms  must  be  provided,  which  may  be  used  also  for  the  preparation  of  the  patient. 
There  ought  to  be  quarters  for  the  surgeons,  and  in  this  room  there  should  be  a 
sufficient  number  of  lockers  to  serve  the  number  of  men  who  operate,  and  since 
modern  surgery  demands  cleanliness  of  person  on  the  part  of  the  surgeons,  it  is 
desirable  to  have  in  the  surgeons'  dressing-room  a  shower  bath,  an  ordinary  bath- 
tub, a  toilet,  and  a  hand  wash-basin. 

In  some  hospitals  there  are  many  medical  visitors  who  come  to  see  surgery;  it 
is  the  custom  for  these  men  to  take  their  coats  and  vests  off  and  to  don  an  opera- 
ting coat  or  gown,  each  institution  being  a  law  unto  itself  as  to  the  character  of 
the  visitor's  gown.  It  is  not  desirable  to  have  these  casual  visitors  frequent  the 
regular  surgeons'  dressing-room,  therefore  there  should  be  a  visitor's  dressing-room 
with  lockers,  a  table  with  writing  material,  perhaps  a  lounge,  and  some  institutions 
have  a  telephone  for  the  use  of  visiting  physicians. 

The  nurses  are  perhaps  the  most  important  factor  of  all  in  the  operating-rooms, 
and,  although  most  surgeons  seem  to  overlook  the  fact  in  their  demands  on  the 
nurses  in  the  operating  service,  these  girls  are  just  ordinary  human  beings,  and 
quite  as  likely  to  become  exhausted  and  fagged  out  as  the  surgeons  themselves, 
and  oftentimes  one  of  them  will  get  sick  while  at  work,  so  that  by  all  means  the 
nurses  ought  to  have  a  room  for  themselves  in  connection  with  the  operating 
suite,  which  should  be  equipped,  just  as  the  surgeons'  dressing  room  is  equipped, 
with  lockers,  a  shower  and  bath,  toilet  and  basin,  and  there  should  be  a  lounge 
in  the  nurses'  room,  so  that  a  tired  girl  may  rest  sometimes. 

Last,  hut  not  least,  there  is  an  immense  amount  of  cleaning  and  janitor  service 
to  lie  performed  in  connection  with  the  surgical  suite,  and  there  ought  to  be  a  small 
room  in  which  to  keep  the  janitor's  supplies,  mops,  buckets,  [adders,  and  brooms. 


48  HOSPITAL   ARCHITECTURE 

And  if  there  could  be  still  another  room,  that  might  be  kept  under  lock  and  key 
for  the  safety  of  the  larger  apparatus  occasionally  called  for  in  the  operating-rooms, 
it  would  be  an  economy,  because  in  many  places  these  things  set  around,  to  be 
fingered  and  handled  by  casual  visitors,  and  oftentimes  they  are  put  out  of  order 
and  are  not  ready  for  use  when  called  for — such  apparatus  as  the  large  cautery, 
the  jury  mast  and  attachments  for  putting  on  body  casts,  the  surgeons'  bone-drill, 
the  battery  for  cystoscopic  work,  and  perhaps  some  of  the  cases  of  the  larger  in- 
struments. 

There  are  many  institutions  that  will  not  have  all  these  rooms,  but  it  is  equally 
certain  that  every  institution  competent  to  handle  modern  surgery  will  have  to 
meet  all  the  requirements  of  such  an  operating  suite  as  has  been  outlined.  In 
other  words,  no  matter  how  small  a  hospital,  there  must  be  instruments,  and  there 
will  have  to  be  a  case  for  them,  and  they  will  have  to  be  kept  in  a  dry  place  or  they 
will  rust  and  soon  become  useless.  There  must  be  supplies  in  even  the  smallest 
hospital,  and  sterile  hot  and  cold  water,  and  the  instruments  will  have  to  be  steril- 
ized, and  one  of  the  worst  possible  things  is  to  boil  instruments  in  the  operating- 
room,  so  that  there  ought  to  be  some  place  in  which  to  do  this  sterilization.  The 
anesthetic  must  be  given,  even  in  the  smallest  hospital,  and  if  it  is  not  to  be  given 
in  the  operating-room  itself,  there  must  be  a  small  room  in  which  to  give  it.  The 
surgeons  and  nurses  must  dress  and  undress,  and  there  certainly  must  be  a  place 
for  them  to  perform  these  offices.  In  many  institutions,  large  as  well  as  small,  all 
sorts  of  makeshifts  will  be  resorted  to  to  meet  the  requirements  that  have  been 
outlined.  Sometimes  the  wash-room,  sterilizing-room,  and  supply  room  are  in 
one;  sometimes  there  is  only  a  closet  for  the  surgeons  to  put  on  their  operating- 
room  paraphernalia,  and  the  nurses  are  compelled  to  use  the  supply  room  for  this 
purpose,  and  a  corner  in  the  same  room  will  perhaps  serve  for  the  janitor's  sup- 
plies. In  such  an  institution  the  anesthetizing-room  will  be  dispensed  with,  and 
patients  will  be  put  to  sleep  on  the  operating  table,  in  spite  of  the  fact  that  some- 
times they  are  almost  frightened  to  death  at  the  sight  of  white-robed,  white-masked 
surgeons  and  nurses  flitting  about. 

Figure  8  shows  rather  an  elaborate  operating  suite  that  seems  to  meet  most 
requirements.  The  plan  provides  for  three  operating-rooms  and  their  auxiliaries. 
This  whole  scheme  may  be  constricted  to  provide  for  one  operating-room  only. 

The  three  operating-rooms  are  side  by  side,  each  having  its  northern  window 
lights,  of  any  design  that  may  be  selected.  There  is  a  side  window  in  each  of  the 
two  end  rooms  for  additional  light  and  air.  All  of  these  rooms  open  by  double 
swinging  doors,  containing  stops  and  checks,  upon  a  common  corridor  of  rotunda 
form,  to  allow  of  the  easy  handling  of  carts.  In  some  operating  suites  the  steriliz- 
ing-room is  placed  between  the  operating-rooms,  with  shelf  window  between  it 
and  each  operating-room,  for  the  handling  of  supplies  and  water;  this  arrangement 
is  unsatisfactory,  because  the  sterilizing-room  is  of  necessity  a  very  hot  place  in 
the  summer  time,  and  nearly  all  sterilizers  emit  at  least  some  steam  into  the  room, 
no  matter  what  preventative  devices  are  used.  Both  the  heat  and  steam  are  ob- 
jectionable in  operating-rooms;  therefore,  it  seems  better  to  have  the  sterilizing 
room  across  the  corridor  from  the  operating  suite,  as  indicated  in  the  drawing. 
The  sterilizing-room,  containing  water,  instruments,  dressing,  and  salt-solution 
sterilizers,  can  be  kept  cool  by  an  exhaust  fan  above  the  window,  which  will  serve 
to  draw  the  hot  air  out  of  doors.  It  would  seem  a  much  more  advantageous  ar- 
rangement if  there  were  a  common  dressing  sterilizer-room  somewhere  else,  in  the 
basement  perhaps,  with  a  sufficient  number  of  sterilizers  to  make  up  supplies  in 
drums  for  all  parts  of  the  house,  and  have  these  supplies  distributed  daily.     The 


ARRANGEMENT   OF   ADMINISTRATIVE    UNITS 


49 


same  may  be  said  of  the  salt-solution  sterilizer,  excepting,  perhaps,  that  in  some 
institutions  these  normal  salines  are  kept  ready  for  use  at  a  temperature  that  will 
make  them  immediately  available,  and  where  that  is  done  perhaps  it  will  be  better 
to  have  the  salt-solution  sterilizer  in  connection  with  the  operating-room  suite. 


L  ■,.-, 


^  i^pw— Jr 


^"T4. 


1 


OpeR_A.*TING  DEPAl 


Fig.  8. 

The  next  room  of  this  suite  on  the  same  side  of  the  general  corridor,  leading  from 
other  parts  of  the  hospital,  will  be  the  supply  room.  The  shelving,  closets,  and 
lockers  of  the  supply  room  will  be  obvious  in  their  arrangement. 

Just  off  this  supply  room  is  a  long  narrow  slit  in  the  wall,  the  blanket  wanner. 
This  is  an  ordinary  laundry  drier,  with  steam  coils  ill  the  rear.      The  carriage  is 


50  HOSPITAL   ARCHITECTURE 

run  in  and  out  on  tracks  just  as  in  the  laundry.  This  little  drier  has  an  immense 
usefulness  in  the  operating-room  suite.  It  practically  does  away  with  the  necessity 
to  warm  beds  by  the  use  of  hot-water  bottles  in  preparation  for  patients  expected 
from. the  operating-room.  Where  this  drier  is  used,  it  is  the  custom  to  hang  the 
horse  full  of  all-wool  blankets,  and  as  many  as  may  be  needed  are  tucked  about 
the  patient  when  he  is  taken  from  the  table  to  the  stretcher,  and  he  can  be  put  into 
bed  when  he  arrives  at  his  room,  with  these  hot  blankets  still  around  him.  Patients 
get  to  bed  in  a  very  much  better  condition,  and  freer  from  the  shock  of  the  opera- 
tion in  this  way,  and  the  peripheral  circulation  is  very  much  hastened  when  the 
patient  is  wrapped  up  in  hot  blankets  immediately  at  the  conclusion  of  the  opera- 
tion, and  the  burning  of  patients  by  hot-water  bottles,  so  common  in  hospitals, 
is  practically  ended.  The  vitality  of  the  patient  under  an  anesthetic,  and  espe- 
cially at  the  end  of  a  long  operation,  is  very  low,  and  a  ho1>water  bottle,  contain- 
ing water  at  120  degrees,  will  oftentimes  make  a  very  serious  burn.  This  little 
hot-blanket  room  practically  does  away  with  all  this  danger.  By  the  time  the 
blankets  are  cold  the  patient  and  the  bed  are  warm,  and  the  blankets  can  then  be 
removed,  sterilized,  and  returned. 

Next  to  the  supply  room  is  the  wash-room,  with  its  hand-basin,  sinks,  gas 
plate,  utensil  sterilizer,  and  a  row  of  shelves;  here  the  soaps  are  made,  sponges 
boiled,  and  instruments  cleaned. 

Still  further  along,  on  this  same  side,  is  the  instrument-room.  There  is  no 
door  between  the  wash-room  and  the  instrument-room,  because  it  is  necessary  to 
keep  the  instruments  very  dry,  which  will  not  be  possible  if  steam  from  the  wash- 
room is  allowed  to  penetrate.  This  instrument-room  should  be  plainly  furnished; 
the  instrument  case  itself  and  a  long  table  will  be  all  the  furniture  required,  with 
the  possible  exception  of  a  white  enameled  stool  or  two  for  the  nurses  to  use  while 
arranging  and  putting  away  the  instruments.  The  last  room  on  this  side  of  the 
corridor  is  for  the  janitor's  stores;  this  room,  if  occasion  requires,  can  be  used  also 
for  keeping  the  larger  apparatus,  where, the  janitor  and  operating-room  orderly 
are  one.  The  average  house  man,  who  would  be  called  upon  to  mop  the  floors  in 
the  operating-room  suite,  would  slap  a  wet  mop  against  a  piece  of  valuable  appa- 
ratus and  rust  it  beyond  all  usefulness  in  a  short  time,  and  the  first  intimation  of 
the  fact  would  be  when  the  instrument  was  called  upon  for  use. 

Let  us  now  go  back  to  the  other  side  of  this  main  corridor,  where  the  first  two 
rooms  are  arranged  for  anesthetizing  the  patient.  These  rooms  ought  to  contain, 
in  the  shape  of  furniture,  an  operating-room  table,  a  cabinet  to  hold  the  anesthet- 
ics and  masks,  and  the  scrubbing-up  material,  such  as  soaps,  ether,  alcohol,  iodin, 
and  brushes.  There  ought  to  be  a  small  anesthetic  table  and  stool,  and  an  ordinary 
table  at  the  side  of  the  room  for  emergency  purposes.  There  ought  to  be  a  basin 
with  hot  and  cold  faucets,  a  brush  and  comb  box  above  the  basin  and  at  the 
side  of  the  mirror,  because  oftentimes  patients  will  come  to  the  hospital  to  take  "a 
whiff"  of  gas  for  some  slight  operation,  and  they  will  want  to  spruce  up  again  and 
go  home.  The  gas-anesthetizing  apparatus  will,  of  course,  be  in  these  rooms,  and 
the  carbonic-acid  freezing  set  for  the  quick  removal  of  warts,  moles,  and  nevi, 
with  the  frost  pencil. 

The  next  room  is  the  nurses'  dressing-room,  with  shower,  toilet,  basin,  and 
couch. 

The  next  room  is  the  surgeons'  dressing-room,  equipped  precisely  like  that  of 
the  nurses',  and,  last  of  all,  the  locker-room  for  visiting  physicians. 

Some  surgeons  choose  to  have,  in  connection  with  the  operating  suite,  a  series 
of  recovery  rooms.     The  advantage  of  this  arrangement  may  be  doubted.     When 


DETAILS    OF   STRUCTURE  51 

the  operation  is  concluded  the  patient  is  asleep,  the  wound  is  fresh,  and  not  yet  sore, 
and  he  would  not  feel  pain  in  any  event;  therefore,  it  would  seem  to  be  good 
practice  to  rush  the  patient,  covered  in  hot  blankets,  back  to  the  bed  where  he  is 
to  remain,  as  quickly  as  possible.  If  the  patient  is  allowed  to  remain  in  a  recovery 
room  on  the  car  for  two  or  three  hours,  or  even  twelve  hours,  he  is  sick  and  sore, 
perhaps  nauseated,  and  it  will  be  very  much  more  painful  and  more  difficult  to 
move  him  then  than  it  would  be  in  the  first  place.  Moreover,  many  times  patients 
need  a  great  deal  of  attention  from  the  nurses  immediately  following  the  opera- 
tion— there  may  be  nausea  and  vomiting.  They  may  need  a  "hypo,"  either 
of  morphin  or  strychnin.  They  may  need  irrigation — abdominal,  subcutaneous, 
or  intravenous — and,  under  any  of  these  circumstances,  it  would  seem  very  prefer- 
able to  have  the  patient  back  in  his  own  bed,  where  he  is  going  to  remain,  as  soon 
after  the  operation  as  possible. 

DETAILS  OF  STRUCTURE 

FOUNDATIONS 

The  type  of  foundation  which  is  to  be  employed  is  an  engineering  question, 
depending  on  the  height  of  the  building  and  the  nature  of  the  soil.  Generally, 
hospitals  are  not  high,  and,  inasmuch  as  their  floor-carrying  requirement  is  very 
low,  the  ordinary  spread  foundations  are  the  most  suitable  and  economic,  and 
in  localities  where  the  contractors  are  conversant  with  reinforced  concrete  con- 
struction the  foundations  should  be  built  of  this  material,  provided  that  the  cost 
of  the  material  compares  favorably  with  the  cost  of  other  materials  for  foundation 
uses  in  the  same  locality.  Reinforced  foundations  save  on  the  excavation  and  on 
the  amount  of  material. 

Rooms  which  are  to  be  used  for  service  cannot  have  the  footings  which  are 
obligatory  when  common  rubble  stone  is  used.  In  some  localities  rubble  stone  is 
so  cheap  that  it  should  be  employed,  but  the  builder  must  weigh  carefully  the 
additional  cost  of  excavating,  and  it  should  be  laid  in  mortar  composed  of  Portland 
cement  and  a  coarse  sand  without  the  admixture  of  lime.  Inasmuch  as  lime  is 
hygroscopic,  a  wall  laid  with  lime  mortar  and  below  ground  will  be  moist  almost 
continuously  and  certainly  intermittently.  Gravel  and  crushed  stone  or  crushed 
slag  are  equally  good  for  mass  concrete  such  as  is  usually  used  in  foundation  walls. 

It  is  not  generally  known  that  ordinary  cement  concrete  is  not  a  dependable 
material  for  the  building  of  waterproof  basements  or  cellars.  To  obtain  such  it  is 
necessary  to  employ  special  mixtures  and  unusual  care,  which  results  in  a  completed 
work  of  unusual  cost. 

The  simplest  arrangement  to  obtain  a  dry  basement  is  to  have  the  elevation  of 
the  basement  floor  several  feet  above  the  drains,  and  to  drain  the  subsoil  under  the 
basement  floors  and  the  ground  surrounding  the  building  by  agricultural  drain 
tile  laid  below  the  level  of  the  basement  floor,  so  that,  if  the  house-drains  and  the 
street-drains  are  of  sufficient  capacity  to  take  off  the  greatest  known  precipita- 
tion for  a  given  time,  it  will  hardly  be  necessary  to  make  any  other  provision  to 
obtain  a  dry  basement,  for  water  will  follow  the  line  of  least  resistance,  and  will 
follow  the  outer  surface  of  the  cellar  wall  to  the  nearest  drain  tile,  unless  the  wall 
is  so  badly  built  that  there  are  actual  channels  for  the  water  through  the  wall. 
The  customary  plastering  of  the  exterior  of  the  wall  with  cement-mortar  will  pre- 
vent much  seepage  if  the  plastering  is  done  reasonably  well.  Where  a  site  is  below 
the  line  of  drainage,  or  where  the  sewers  are  so  small  that  their  carrying  capacity 


52  HOSPITAL   ARCHITECTURE 

is  overtaxed,  it  will  be  necessary  to  make  special  provisions,  either  by  making  the 
floors  and  walls  actually  waterproof,  as  though  the  cellar  or  basement  were  the  hull 
of  a  vessel  floating  in  the  water,  or  by  providing  piping  for  the  interception  of  seep- 
age at  every  possible  point  of  entrance,  and  providing  channels  which  will  be  the 
line  of  least  resistance  and  lead  the  water  to  basins  which  can  be  drained  by  auto- 
matic ejectors.  In  very  small  cellars  an  automatic  water-lift  will  be  sufficient, 
and  these  are  of  low  price,  but  in  large  establishments,  or  where  considerable 
ground  water  must  be  removed,  power  ejectors  are  necessary.  The  water  can  be 
removed  by  the  use  of  a  steam  ejector,  but  this  is  an  expensive  method,  not  auto- 
matic, and  limited.  Automatic  electric  bilge-pumps  and  compressed-air  ejectors 
have  been  in  use  for  many  years  and  are  satisfactory ;  they  can  be  obtained  in  units 
of  many  sizes  and  prices,  and  are  usually  installed  in  duplicate,  to  have  one  in 
reserve  in  the  event  that  one  of  them  fails  to  operate. 

The  waterproofing  of  walls  and  cellar  floors  can  be  done  with  a  mixture  of 
special  compounds  and  Portland  cement,  and  troweling  these  mortars  on  the 
surfaces.  There  are  a  number  of  very  good  mixtures  on  the  market.  The  dis- 
advantage of  such  a  method  is  that  the  slightest  settlement  may  open  a  hair  crack 
in  the  floor  or  wall  and  permit  the  ingress  of  water.  The  building  of  specially 
prepared  felts,  asphalt,  or  bitumen  into  floors,  and  joining  these  into  the  walls 
and  continuing  the  same  as  an  envelope  on  the  outside  of  the  walls  to  the  ground 
surface,  is  the  most  certain  method  of  building  a  permanently  water-tight  vessel, 
and  it  has  been  most  generally  used  in  works  of  importance,  such  as  tunnels  and 
subways.  This  is  also  an  expensive  operation,  on  account  of  the  special  materials, 
care,  and  workmanship,  and  is  not  employed  except  in  special  cases. 

WALLS  AND  FACINGS 

The  means  at  the  disposal  of  the  institution  will  usually  dictate  the  facing  of 
the  exterior  wall,  and,  granted  that  the  hospital  must  have  incombustible  walls, 
such  as  concrete  or  masonry,  and  that  frame  walls  are  not  to  be  considered,  the 
relative  cost  of  the  different  materials  is  about  in  the  following  order  in  the  vicinity 
of  Chicago: 

Hollow  tile  unplastered,  common  brick,  which  can  be  laid  in  red  mortar, 
paving  brick,  cement  blocks,  common  brick  plastered  with  cement,  or  common 
brick  plastered  in  pebble-dash  cement;  hollow  tile  plastered  in  pebble  dash;  a 
high  grade  of  pressed  brick,  then  limestones,  sandstones,  and  granite.  An  ex- 
terior of  paving  brick,  trimmed  with  granite  for  the  base  courses  and  entrance 
steps,  and  stone  or  terra-cotta  trimmings,  will  be  durable  and  suitable  for  a  hospi- 
tal, and  it  will  probably  serve  the  public  best  if  the  further  money  which  may  be 
at  the  disposal  of  the  institution  is  used  for  an  extension  of  the  work  of  the  insti- 
tution, and  a  more  elaborate  use  of  costly  materials  on  the  exterior  of  an  institu- 
tion may  be  considered  a  waste. 

Practically  all  stones  and  concrete  except  granite  absorb  considerable  water, 
which  discolors  them,  and  is  also  very  likely  to  cause  deterioration  by  the  action 
of  frost;  consequently  a  base  of  granite  directly  on  the  ground  is  very  desirable  to 
keep  the  base  of  the  wall  dry  and  in  good  appearance.  Notwithstanding  that  there 
may  be  a  waterproofing  course  through  the  walls  at  the  level  of  the  ground,  the 
splashing  of  the  storm  water  on  the  ground  or  on  walks  and  rebounding  to  the  walls 
will  frequently  water-soak  the  base  of  the  walls,  and,  whether  of  brick,  terra-cotta, 
concrete,  or  stone,  this  will  have  its  effect  in  time;  consequently  an  impervious 
material,  such  as  granite,  is  most  desirable. 


DKTAILS    OF   STRUCTURE  .>} 

Generally  brick  is  the  mosl  economic  incombustible  material.     In  localities 

where  the  price  of  brick  or  of  skilled  mason  labor  is  high,  walls  of  hollow  concrete 
blocks  or  of  monolithic  concrete  may  be  an  economy.  The  exterior  treatment 
of  such  walls  is,  however,  rather  difficult  and  somewhat  expensive.  If  the  material 
is  to  hi'  of  good  appearance  as  it  comes  from  the  forms,  these  must  be  made  very 
carefully,  and  are,  therefore,  expensive.  The  concrete  must  be  mixed  with  care- 
fully gauged  materials,  and  placed  against  the  forms  with  extraordinary  care,  and 
even  then  ragged  spots  often  appear  on  account  of  the  leakage  of  water  through 
the  forms,  and  an  invisible  repair  is  well-nigh  impossible.  It  is  sometimes  feasible 
to  remove  the  forms  of  vertical  portions  very  soon  after  the  material  has  been 
placed,  and  wash  the  fine  material  from  the  surface  by  the  use  of  stiff  brushes  and 
clean  water.  When  this  is  done  the  finished  surface  will  have  the  appearance  of  a 
rubbed  natural  stone,  and  is  a  highly  satisfactory  method  for  small  pieces  of 
work.  Another  method  is  to  wash  the  concrete,  after  the  forms  have  been  re- 
moved, with  a  dilute  acid,  which  will  dissolve  the  fine  cement  on  the  surface  and 
also  produce  a  pebbled  appearance. 

Granite  Mix. — Washing  the  surface  of  concrete  when  still  new,  or  washing  it 
with  strong  acid,  removes  the  cement  and  exposes  the  aggregate,  which  should  be 
composed  of  material  broken  into  comparatively  small  pieces  which  have  small 
voids  in  between  them.  The  low-priced  materials,  such  as  coarse  sand,  fine  gravel, 
or  crushed  stone,  generally  do  not  have  a  desirable  color  when  so  exposed.  In- 
asmuch as  the  mixtures  of  fine  stuff  are  not  advisable  or  economic  for  the  full 
thickness  of  the  walls,  these  mixtures  must  be  placed  against  the  forms  in  thin 
layers  and  in  courses,  as  the  height  of  the  whole  of  the  wall  is  increased.  The 
facing  of  fine  stuff  is  backed  with  the  coarse  mixture  and  these  sequences  until 
the  completion  of  the  work. 

The  facing  of  fine  stuff  does  not  require  much  material,  and  can,  therefore, 
be  made  of  materials  which  will  have  a  more  pleasing  color  than  sand  or  crushed 
stone  for  a  small  additional  percentage  of  the  cost  of  the  whole  concrete  work. 

The  mixture  of  5  bags  of  granite  screened  through  a  No.  5  sieve,  2  bags  of 
Blanc  white  cement,  and  i  bag  of  ground  mica  has  made  a  concrete  which  resembles 
dressed  granite  of  the  same  kind  as  used  in  the  mixture  so  closely  that  a  layman 
could  hardly  detect  the  imitation.  Mixtures  of  crushed  red  and  crushed  black 
granite  with  mica  and  white  cement  and  many  other  combinations  are  possible. 

The  design  of  concrete  work  is  sometimes  such  that  it  is  impossible  to  remove 
the  forms  early  enough  to  wash  the  surface  with  water  or  acid,  and  it  is  then  im- 
possible to  remove  the  surface  cement  in  this  manner,  but  the  texture  and  color 
can  be  exposed  by  bush  hammering  the  surfaces  in  the  same  manner  as  natural 
stone  is  bush  hammered.     This  will  result  in  a  very  satisfactory  surface  finish. 

Journeyman  mechanics  capable  of  executing  such  work  are  as  yet  very  rare. 
A  few  of  the  larger  construction  companies  have  trained  a  limited  number  of  nun 
to  execute  such  work,  but  as  yet  such  labor  is  not  an  ordinary  commodity  on  which 
Contractors  will  bid  on  small  profits  and  narrow  margins  for  contingencies. 

The  difficulty  of  preparing  concrete  blocks  of  uniform  or  equal  absorption, 
and  the  unartistic  appearance  of  these  blocks,  which  are  often  too  large  in  scale 
for  the  wall  surface,  or  of  poor  proportion,  makes  them  unsatisfactory  material  for 
the  facing  of  buildings.  Unequal  absorption  causes  a  spotty  appearance  niter  :i 
rain-storm,  and  also  causes  some  of  the  pieces  to  absorb  dust  and  SOOt.  The 
unsatisfactory  appearance  of  concrete  block  buildings  is  largely  caused  by  unwise 
economy,  which  prompts  the  use  of  as  few  molds  as  possible;  consequently  the 
design  does  not  follow  the  law  of  proportion.      In  order  to  design  the  blocks  accord- 


54 


HOSPITAL    ARCHITECTURE 


ing  to  proper  laws  of  proportion  a  large  number  of  dies  or  forms  are  necessary, 
and  the  cost  will  then  approach,  and  possibly  exceed,  that  of  a  monolithic  concrete 
construction,  except  in  the  case  of  low  buildings,  in  which  the  walls  do  not  carry 
much  weight  in  proportion  to  their  thickness.  The  appearance  of  concrete-block 
houses  can  be  made  interesting  and  possibly  beautiful  by  modeling  and  courses, 
or  by  obtaining  an  individual  texture,  a  texture  which  will  not  be  an  imitation  of 
natural  stone  or  of  stamped  steel  ornament,  which,  unfortunately,  forms  the  basis 
for  most  of  the  ornamental  dies  now  on  the  market. 


Fig.  9. — Walls  of  hollow  tile  plastered  in  pebble  dash. 


The  ornament  on  concrete  blocks  is  limited  by  the  same  difficulty  which  sur- 
rounds the  manufacture  of  satisfactory  stamped  steel  ornament,  which  is  that  the 
stamping  does  not  permit  sharp  outlines  or  undercutting  of  the  ornament,  both 
of  which  are  necessary  to  obtain  an  artistic  play  of  light  and  shade.  It  is  neces- 
sary to  use  a  comparatively  dry  mixture  of  sand,  cement,  and  water  to  produce 
the  blocks  rapidly;  such  a  mixture  is  porous,  and  is  the  cause  of  the  spotty  and  water- 
soaked  appearance  of  a  cement  block  house  after  a  rain-storm. 


DETAILS    OF    STRICTURE 


.-,.-, 


Hollow  Clay  Tile. — Hollow  clay  tiles  are  made  of  varying  thicknesses,  usu- 
ally 12  by  12  inches,  and  3,  4,  6,  8,  10,  and  12  inches  in  thickness.  Those  thicker 
than  S  inches  are  usually  termed  "wall  blocks."  Well-burned  clay  tile  does  not 
disintegrate  in  moist  or  damp  places.  They  arc  suitable  for  use  for  buildings  of 
any  kind  where  the  unit  stresses  are  not  too  great.  Special  blocks  for  high  unit 
stresses  can  be  obtained,  so  that  this  form  of  construction,  supporting  fireproof 
floors,  can  be  used  for  buildings  having  as  many  as  five  stories,  and  is  shown 
in  Fig.  9,  photographed  from  material  made  by  the  Laclede  Christy  Co.,  of 
St.  Louis,  Mo. 

The  exterior  walls  in  colder  climates — that  is,  in  localities  north  of  a  line  ap- 
proximately on  the  30th  degree  isotherm  for  January — should  have  a  hollow 
space  to  retard  the  loss  of  heat  and  to  prevent  the  discharge  of  moisture  through 
the  walls  into  the  building.  Such  spaces  are  formed  by  furring  the  inside  of  the 
building  with  hollow  clay  tile  or  hollow'  gypsum  boards,  also  by  the  use  of  metal 
furring,  all  of  which  is  described  in  another  paragraph. 

The  webs  of  the  hollow  building  blocks  appear  to  transmit  heat  to  such  an  ex- 
tent that  moisture  is  condensed  on  the  inside  or  outside  of  walls  built  of  such  blocks 
opposite  the  webs  when  the  conditions  are  favorable  to  condensation,  unless  the 
inner  surface  of  the  blocks  is  sealed  or  protected  by  bituminous  or  asphaltic  com- 
pound. Hollow  bricks  are  sometimes  used  for  the  inner  course  of  brick  walls,  but 
the  same  objection  holds  in  their  use. 

FLOOR  CONSTRUCTION 

The  invention  of  reinforced  concrete  and  reinforced  tile  construction  has 
produced  a  fireproof  construction  which  increases  the  cost  of  a  hospital  only  from 
10  to  20  per  cent,  above  the  cost  of  one  in  which  wood-construction  floors  are  to 
be  used,  depending  on  the  kind  of  floor  surfacing  selected. 


TTTWryr 


»!«?•- 


CcwcttTc  CouurAN  E  "     I   J 

Fig.  10. — Solid  concrete,  skeleton  construction. 


High  steep  roofs  of  fireproof  construction  are  expensive,  requiring  special  forms 
which  are  used  only  once,  more  material  than  a  floor,  and  an  expensive  covering, 
such  as  slate  or  tile.  Where  a  roof  of  such  a  form  is  considered  an  esthetic  neces- 
sity, and  money  is  not  on  hand  to  build  it  of  enduring  construction,  it  should  have 
steel  framing  and  2-  or  3-inch  thick  planking,  approximating  mill  construction, 
with  an  unobstructed  attic  cement-finished  floor  below  it,  sloping  to  outlets  in  the 
outer  walls,  thereby  affording  protection  from  storm  water  to  the  lower  stories  in 
the  event  of  a  partial  destruction  of  the  roof  by  tire. 

The  most  popular  forms  of  fire-resisting  construction  are  the  following,  viz.: 
(a)   licinforccil  Concrete.  Flat  Slabs   (fig.   10).-    Its  cheapest   application  is  for 
Comparatively  short  spans,  probably  15  feet  is  the  economic  limit,  the  thickness 


56 


HOSPITAL   ARCHITECTURE 


will  vary  from  4  to  6  inches;  transmits  sound  easily  if  covered  with  a  hard  floor; 
plaster  adhesion  to  smooth  cement  surface  is  not  certain;  only  small  electric  and 
gas  pipes  can  be  embedded  within  the  concrete;  plumbing  and  steam  pipes  not  only 
weaken  the  floor  on  account  of  their  size,  but  must  lie  free  to  expand  and  contract, 
consequently  pipes  hanging  from  such  construction  must  be  concealed  by  sus- 
pended or  false  ceilings  in  certain  rooms,  inasmuch  as  laying  plumbing  pipes  on 
the  construction  and  raising  a  bath-room  floor  not  only  increases  the  cost,  but  the 
steps  which  are  then  necessary  at  a  bath-room  door  are  very  objectionable. 


Kg.  11. — Johnson  type,  tile  and  concrete,  bearing  walls. 

(b)  Reinforced  Concrete  Ribs  and  Slabs  (Fig.  11). — When  the  spans  are  too  great 
for  an  economic  use  of  flat  slabs,  ribs  or  beams  of  greater  depth  are  introduced, 
spaced  at  intervals  to  obtain  thin  slabs  and  beams  of  proper  proportion;  this  form 
of  floor  is  subject  to  the  same  objections  as  noted  under  type  (a),  but  to  the  further 
objection  that  the  ribs  cannot  always  be  spaced  symmetric  to  the  walls  of  a  room 
and  also  obstruct  light;  if  a  metal  lath-and-plaster  ceiling  is  suspended  below  such 
construction  its  cost  is  increased  considerably  above  that  of  some  of  the  flat  ceil- 
ing constructions  described  below. 


Fig.  12. — Concrete,  rib,  and  tile,  skeleton  construction. 

(c)  Tile  and  Reinforced  Concrete. — The  kind  shown  in  Fig.  12  contains  a  woven 
wire  fabric  in  the  lower  layer  of  concrete  in  short  spans  and  rods  in  longer  spans; 
it  also  requires  a  strong  concrete  layer  on  its  upper  surface,  firmly  united  to  the 
tile;  it  is  a  fairly  economic  construction;  it  affords  considerable  resistance  to  the 
transmission  of  sound  and  presents  a  flat  ceiling. 

The  objections  to  this  form  of  construction  are  that  the  surface  to  be  plas- 
tered is  concrete,  and  that  certain  stresses  must  be  transmitted  through  the  tile 
to  obtain  a  safe  floor.  This  is  obtained  by  the  mortar  bond  and  is  not  certain  to 
occur  everywhere. 


DKTAILS    OF    STKIITI   l{K 


57 


(d)  Reinforced  concrete  rib  and  tile  construction  (Fig.  13)  shows  that  this 
form  of  construction  consists  of  two  parts:  the  reinforced  concrete  joist  and  the 
hollow  tile  between;  this  is  only  a  filling,  and  may  he  cut  out  or  formed  into  chan- 
nels for  the  reception  of  pipes  and  conduits.  It  requires  very  simple  forms  for  erec- 
tion, affords  a  flat  ceiling  resistance  to  the  transmission  of  sound,  a  good  surface 
for  plastering,  and  space  for  the  reception  of  piping  of  the  size  ordinarily  required. 
If  an  unusually  large  space  is  required  it  can  be  formed  as  shown  in  the  illustration. 

Steel  und  Tilt . — Steel  beams  and  girders,  connected  together  into  a  floor  sys- 
tem, or  combined  with  columns  into  a  skeleton  steel  construction,  are  too  well 
known  to  require  description. 

In  the  best  form  of  this  construction  (Fig.  14)  the  spaces  between  the  beams 
are  filled  with  hollow  clay  tile,  or  sometimes  concrete  is  used,  but  unless  the  ar- 
rangement of  the  building  is  unusually  simple  and  the  price  of  steel  abnor- 
mally low  none  of  these  forms  of  construction  can  approach  the  other  four  types 
described  above  in  point  of  cheapness,  and  can  never  do  so  if  there  are  men  trained 
and  experienced  in  reinforced  concrete  construction  in  the  field. 

Types  (a)  and  (b)  are  very  useful  for  rooms  and  first  floors  which  are  not  over 
sleeping  or  living  apartments,  but  the  types  should  be  the  same  throughout  a 
building,  to  permit  of  the  frequent  use  of  one  set  of  forms. 


Fig.  13. — Tile  arch  construction. 


A  finished  cement  surface  can  be  obtained  with  types  (a)  and  (6)  at  a  slight 
additional  cost;  therefore  suitable  for  laundries  and  storerooms. 

The  four  types  are  drawn  to  be  suitable  for  linoleum  or  magnesia-cement  floors, 
or  the  kind  of  wood  flooring  which  is  secured  to  the  cement  by  asphalt  and  bitumen, 
described  in  a  later  paragraph. 

Where  ordinary  wood  flooring  is  described  it  is  necessary  to  lay  wood-nailing 
strips  in  a  meager  concrete,  such  as  cinder  concrete,  on  any  of  these  types. 

Skeleton  concrete  construction  or  wall-supported  floors  may  be  combined  with 
any  of  these  types,  but  their  choice  is  an  engineering  question  in  which  height  of 
building,  thickness  of  walls,  and  cost  of  walls  are  important  factors  too  intricate 
and  involved  for  the  scope  of  this  work. 

The  much-advertised  systems  of  construction  afford  some  one  an  opportunity 
to  obtain  a  much  higher  price  for  reinforcing  steel,  because  of  a  valueless  change 
of  shape  than  for  the  ordinary  stock  shapes  of  the  steel  trade,  or  some  one  is  ob- 
taining engineering  services  and  working  drawings  from  a  "System  Company," 
thereby  stifling  competition  and  permitting  the  "System  Company"  to  recover 
the  cost  of  the  engineering  services  in  an  excessive  unit  price  of  the  steel  or  an 


58 


HOSPITAL    ARCHITECTURE 


unnecessary  quantity;  the  cost  of  advertising  and  engineering  must  be  paid  for 
somewhere,  and  will  increase  the  cost  of  the  building,  because  it  will  be  paid  by 
the  owners  in  one  form  or  another. 

To  permit  contractors  who  are  in  the  same  position  as  tradesmen  to  write  speci- 
fications and  make  any  portion  of  the  plans  is  pernicious  and  often  immoral.  Such 
conduct  of  constructive  work  permits  irregularities  and  should  not  be  tolerated. 
The  architect  should  be  paid  a  fair  commision,  but  he  must  be  what  the  title  im- 
plies, competent  to  analyze  the  situation,  form  proper  conclusions,  and  design 
the  whole  of  the  work,  so  that  bona  fide  competitive  proposals  will  be  submitted 
by  the  best  and  most  reliable  contractors  in  the  field. 


Fig.  14. — Steel  and  tile  construction. 

The  architect  who  has  had  the  most  experience  and  the  best  training  will  obtain 
the  most  for  the  money  expended,  and  notwithstanding  his  commission  may  be 
more  than  that  asked  by  others,  he  will  return  it  many  times  in  a  more  suitable 
design. 

The  old  saying  that  the  highest-priced  man  usually  is  the  best  is  as  true  in 
building  as  in  many  other  human  activities. 


ROOFING 

The  slope  or  pitch  of  the  roof  depends  on  the  design  and  the  available  funds. 
Steep  pitched  roofs  which  are  visible  and  ornamental  must  be  covered  with  slate, 
tile,  or  copper  laid  with  ornamental  seams.     Such  roofs  are  so  well  known  that 


DETAILS    OF    STRUCTURE  59 

they  require  no  description.  Stamped  tin,  galvanized  iron,  or  copper  shingles 
are  offered  in  imitation  of  molded  roofing  tile,  hut,  inasmuch  as  they  are  an  imi- 
tation and  represent  something  which  they  are  not,  they  are  an  esthetic  abomina- 
tion. They  arc  no  cheaper  than  a  well-made  metal  roof,  and,  inasmuch  as  they 
must  lie  painted,  they  present,  no  advantage  over  the  older  form,  and  have  the 
disadvantage  of  enclosing  surfaces  which  may  be  attacked  by  moisture  and  can- 
not be  reached  by  the  paint  brush. 

The  ordinary  felt  and  composition  roofing  requires  no  description,  and  if  laid 
by  an  established  and  reliable  roofer,  who  is  paid  a  fair  price,  such  roofs  have  a 
long  life.  Their  weakest  point  is  in  the  junction  between  the  roof  and  the  walls. 
Heretofore  this  has  been  made  tight  by  inserting  a  strip  of  wood  into  the  wall,  and 
securing  the  felt  to  the  same  by  a  wooden  cleating  strip,  covering  the  whole  with 
tar  and  pitch.  The  air  being  thereby  excluded  from  the  wood,  this  is  subject  to 
dry  rot,  and,  inasmuch  as  the  gravel  cannot  stand  on  the  vertical  surfaces,  the 
volatile  oil  in  the  tar,  pitch,  and  roofing  felt  is  soon  distilled  by  direct  sun-rays,  so 
that  the  roofing  becomes  brittle  and  nails  lose  their  hold.  This  objection  has  been 
largely  overcome  by  a  new  form  of  clay  tile  block  having  a  groove,  into  which  the 
felt  is  wedged,  and  termed  a  "raggle  block."  When,  in  combination  with  this 
block,  the  angle  between  the  roof  and  wall  is  rounded  off,  a  permanent  device  has 
been  substituted  for  the  vulnerable  point.  Few  of  the  many  kinds  of  prepared 
roofing  now  on  the  market  are  as  good  as  a  good  felt  composition  and  gravel  roof. 
Their  reason  for  existence  is  largely  the  lack  of  skilled  labor  in  small  towns  or  remote 
localities,  where  there  is  not  sufficient  work  to  employ  composition  roofers  con- 
stantly. The  special  roofs  containing  high-grade  felt  or  burlap  in  combination 
with  asphaltic  compounds  are  excellent,  and  the  companies  manufacturing  such 
material  will  send  their  experts  to  lay  such  roofs  almost  any  distance  if  they  are  of 
sufficient  size. 

A  roof  to  be  used  as  a  promenade  or  roof  garden  must  have  a  special  surface; 
level  wooden  floors  with  open  joints  blocked  up  on  the  roof  are  often  used,  but  these 
are  not  only  a  fire  hazard,  but  objectionable  on  account  of  loss  of  small  articles 
through  the  open  joints,  rotting  of  the  wood,  and  odors  from  the  enclosed  space. 

Monolithic  Portland  cement  roofs,  reinforced  to  guard  against  cracking  from 
expansion,  contraction,  or  unequal  settlement,  and  having  a  waterproofing  com- 
pound in  the  top  dressing,  may  be  used  without  any  other  roofing  beneath  if  the 
dimension  of  the  roof  between  the  walls  is  not  large,  but  as  the  size  increases  the 
danger  of  cracking  increases,  and  if  such  slabs  form  the  full  thickness  of  the  roof 
condensation  will  gather  on  the  ceiling  below  in  cold  weather,  which  will  drip  to 
an  annoying  extent.  Roofs  must  be  insulated  to  retard  the  rapid  loss  of  heat, 
either  by  the  use  of  a  hollow  tile  construction  or  the  forming  of  an  attic  space,  the 
temperature  of  which  would  be  a  mean  between  the  room  and  the  outdoor  tempera- 
ture, or  by  a  filling  of  dry  cinders  on  the  structural  portion  of  the  roof.  It  is 
usually  more  economic  to  build  a  horizontal  roof  construction  and  obtain  the 
pitch  necessary  to  drain  storm-water  by  a  filling,  provided  the  roof  is  a  composi- 
tion roof  having  a  pitch  of  about  i  inch  vertical  per  foot  horizontal  measurement. 
\\  hen  filling  of  this  kind  is  vised  the  upper  surface  should  be  compacted  by  rolling, 
and  covered  with  a  1-inch  thickness  of  strong  Portland  cement  mortar  to  provide 
a  firm  foundation  for  a  felt  and  composition  roof.  If  the  roof  is  not  to  serve  as  a 
garden,  the  felt  should  be  covered  with  screened  gravel  as  for  any  other  composition 
roof,  but  if  it  is  to  serve  as  a  garden,  it  should  have  six  thicknesses  of  felt  everywhere 
of  G-ply,  then  mopped  with  hot  asphalt  compound  and  covered  with  a  layer  of 
Hat  red  tile  made  for  this  purpose  in  Akron,  Ohio,  and  measuring  G  by  0  inches,  1 


60  HOSPITAL    ARCHITECTURE 

inch  in  thickness,  and  scored  with  deep  grooves  on  the  underside,  which  assist  the 
adhesion  of  these  tiles  to  the  roof.  Such  tile  are  laid  with  a  sliding  movement, 
forcing  the  compound  into  and  over  the  joints;  the  excess  of  material  is  cut  off  after 
a  few  days.  Such  roofs  have  an  attractive  appearance  and  usually  require  no  re- 
pairs for  twenty  to  twenty-five  years. 

Small  cement  tile  or  cement  work  like  sidewalk  work  may  also  be  used  in  the 
same  manner,  but,  inasmuch  as  the  Akron  tile  are  impervious,  it  is  more  certain  of 
leading  all  storm- water  to  the  gutters  and  conductors.  The  comparative  cost  of 
different  kinds  of  roofing  are  as  follows,  and  based  on  the  square  of  100  feet  (10  by 
10): 

Variegated  green  and  purple  slate S13.00 

Black  slate 15.00 

Five-ply  felt  and  composition  roofing 5.00 

Portland  cement  slabs  on  6-ply  felt  for  roof  gardens 21.00 

Flat  red  terra-cotta  tile  on  6-ply  felt  for  roof  gardens 24.00 

Tile  roofs,  interlocking  red  tile 19.00 

Interlocking  green  dull  glazed  tile 27.00 

Interlocking  green  high  glazed  tile 29.00 

Red  Spanish  dull  tile 22.00 

Green  Spanish  high  glazed  tile 34.00 

Red  shingle  tile 23.00 

Dull  glazed  shingle  tile 30.00 

High  glazed  shingle  tile 32.00 

FLOOR  SURFAONGS 

The  requisites  for  a  satisfactory  floor  for  hospital  purposes  are  many.  The 
floor  should  be  impervious,  it  should  be  monolithic  or  jointless,  elastic,  noiseless, 
non-slippery,  of  pleasing  appearance,  easily  cleansed,  and  economic  of  mainte- 
nance. It  is  almost  impossible  to  find  a  floor  which  will  have  all  of  these  quali- 
ties. 

Wood. — The  cheapest  serviceable  floor  is  a  matched  hard  maple  floor,  yf-inch 
thick,  and  having  a  face  from  2  to  2\  inches  wide,  tongued  and  grooved  on  the 
edges  as  well  as  on  the  ends,  also  bored  for  nailing.  Such  flooring,  including 
labor  of  laying,  nails,  scraping,  shellacking,  and  varnishing  two  coats  will  cost 
about  10  cents  per  square  foot,  and  to  this  the  cost  of  nailing  strips  and  cinder 
concrete  filling  between  such  strips  must  be  added.  The  strips  used  are  of  hem- 
lock, 2  inches  thick  and  4  inches  wide,  beveled  on  both  edges,  so  that  the  con- 
crete filling  will  hold  the  strips  and  prevent  these  from  rising.  The  cost  of  the 
strips  and  concrete  filling  is  about  5  cents  per  square  foot,  and  this  cost  of  15  cents 
must  be  added  to  the  cost  of  subconstruction  if  ordinary  wood  flooring  is  used. 
Slash-sawed  southern  yellow  pine  splinters  and  is  unfit  for  flooring,  and  such  wood 
must  be  quarter-sawed  to  make  a  satisfactory  floor.  Its  cost  is  then  about  the 
same  as  the  maple  flooring  described,  but  not  as  serviceable.  It  has  the  further 
disadvantage  of  not  retaining  a  varnished  finish  as  well  as  other  hard  woods,  and 
apparently  the  great  quantities  of  resin  do  not  combine  permanently  with  shellac 
and  varnish. 

Oak  flooring  of  the  same  dimensions,  and  manufactured  in  the  same  manner 
as  maple  flooring,  is  well  known,  and  there  are  the  same  objections  to  its  use;  the 
cost  is  about  2  cents  per  square  foot  more  than  the  maple  for  plain  oak  floors,  and 
there  will  be  a  larger  proportion  of  short  pieces,  from  2  to  4  feet  in  length. 

High-grade  oak  flooring,  such  as  quarter-sawed  white  oak,  costs  from  5  to 
6  cents  per  square  foot  more  than  maple  flooring,  but  plain  sawed  is  fully  as  ser- 
viceable as  quarter-sawed. 


DETAILS    OF    STRUCTURE  fil 

Wood  is  slashed,  or  plain  sawn,  when  the  log  is  cut  into  boards  by  parallel  saw 
cuts;  quarter-sawed  wood  is  obtained  by  sawing  a  log  into  four  equal-sized  pieces 
by  two  saw  cuts  at  right  angles  to  each  other,  and  each  of  these  quarters  cut  into 
smaller  pieces  by  cuts  parallel  to  radii. 

The  general  objection  to  wood  floors  is  the  cost  and  difficulty  of  maintenance, 
also  the  large  number  of  joint  openings,  which  increase  in  size  as  the  wood  ages, 
and  form  innumerable  recesses  which  cannot  be  cleaned  and  which  may  harbor 
objectionable  germs.  It  is  also  difficult  to  join  wood  floors  to  coved  bases  and  the 
bases  to  the  walls. 

Only  varnishes  of  the  very  best  quality  will  wear  satisfactorily,  and  then  only 
for  a  comparatively  short  time,  and  to  maintain  such  floors  in  proper  appearance 
requires  a  continuous  expense  for  labor  and  for  costly  varnish.  The  varnish  is 
quickly  destroyed  by  use  of  hot  water,  soap,  and  brush,  and  nothing  destroys  the 
finish  of  the  floor  more  quickly  than  an  industrious  scrub  woman.  It  is  well 
known  that  tepid  water,  with  a  light  soapsud  and  a  rag,  will  remove  dust  and  dirt 
from  a  varnished  surface  without  attacking  it.  This  is  rather  slow  work,  and  it 
appears  to  be  impossible  to  have  the  help  available  for  such  kind  of  work  pay  any 
attention  to  this  requirement. 

Maple  floors  can  be  finished  in  a  fairly  satisfactory  manner  by  giving  them 
coats  of  boiled  linseed  oil  mixed  with  turpentine  and  japan.  The  first  coat  will 
soak  into  the  wood,  and  in  drying  quickly  fills  the  pores,  so  that  a  second  coat  will 
dry  on  the  surface  similar  in  appearance  to  varnish,  but  not  as  durable.  Oak 
floors  should  be  filled  with  a  mineral  filler  in  hospital  use  to  close  the  numerous 
pores,  shellacked  one  coat  and  varnished  two  coats.  A  very  serviceable  and  com- 
paratively inexpensive  finish  can  be  obtained  on  oak  by  rubbing  the  wood,  after 
filling,  with  boiled  linseed  oil  and  pumice  stone.  This  will  leave  a  velvety,  dead 
finish,  which  can  be  constantly  maintained  by  the  house  service,  and  can  be  walked 
on  immediately  after  completion. 

The  oak  and  maple  flooring  will  stain  from  water  if  wet  before  it  is  treated 
with  oil  or  varnish.  This  is  especially  the  case  with  oak,  so  that  if  the  varnish  is 
scrubbed  off  the  oak  will  turn  a  blue  black,  and  its  original  color  cannot  be  regained 
except  by  scraping  away  the  wood  to  a  considerable  depth. 

A  form  of  wood  flooring  which  is  used  considerably  in  European  hospitals,  and 
also  in  some  American  institutions,  consists  of  pieces  of  oak  about  18  inches  in 
length,  tongued  on  one  side  and  one  edge,  and  grooved  on  the  other  side  and  edge, 
so  that  these  pieces  can  be  laid  together  in  herring-bone  pattern.  These  strips 
are  molded  in  various  forms  of  dovetailing  on  the  underside,  according  to  the 
respective  makers  or  patentees.  Such  material  is  laid  in  hot  asphalt  or  bitumen, 
which  is  spread  upon  the  floor  in  a  thin  layer,  and  each  piece  is  successively  pushed 
into  place,  forcing  some  of  the  bitumen  into  the  joints  and  filling  these  to  the  sur- 
face; the  excess  is  cut  off,  and  the  floors  then  planed  and  scraped  by  hand  or  polished 
with  an  electric  floor  surfacer.  Such  floors  do  not  have  the  objectionable  open 
joints,  but  the  difficulty  of  maintaining  a  satisfactory  appearance  is  fully  as  great 
as  it  is  with  other  wooden  floors,  but  it  is  likely  that  this  difficulty  will  soon  be 
overcome  by  the  use  of  oiling  machines,  designed  similar  to  carpet  sweepers  and 
electric  rotary  polishers.  The  floors  laid  in  this  manner  cost  about  25  cents  per 
square  foot,  and  if  a  building  is  of  reinforced  concrete  construction,  an  additional 
4  or  5  cents  per  square  foot  must  be  spent  to  prepare  a  smooth  surface  on  the 
structural  concrete.  If  the  building  is  of  hollow  tile  fireproof  construction,  from 
9  cents  upward  for  a  thickness  of  about  3  inches  must  In-  expended  to  prepare  a 
surface  suitable  for  laying  such  a  herring-bone  floor.     The  junction  with  the  walls 


62 


HOSPITAL   ARCHITECTURE 


is  fully  as  difficult  with  this  kind  of  flooring  as  with  other  wooden  flooring,  and 
it  will  probably  be  necessary  to  employ  a  coved  base  of  magnesia  cement,  which 
will  be  described  later. 

Linoleum  has  been  found  to  be  fairly  satisfactory  when  used  in  the  ordinary 
thicknesses  and  laid  in  the  ordinary  manner,  but  when  this  material  is  used  in  the 
heavy  grade  known  as  "battleship"  linoleum,  and  cemented  to  the  foundation, 
it  is  a  very  superior  floor,  filling  almost  every  one  of  the  requisites  of  a  perfect 
hospital  floor.  The  foundations  should  be  trowel-finished  Portland  cement,  made 
about  \  inch,  or  the  thickness  of  the  linoleum  below  the  edge  of  the  baseboard. 

This  form  of  flooring  has  been  in  use  in 
some  of  the  large  hospitals  of  Germany  for 
several  years,  and  will  probably  crowd 
out  every  other  form.  In  that  country  the 
material  is  laid  on  the  floor  loosely  and 
allowed  to  expand,  contract,  and  accom- 
modate itself  to  the  new  condition,  and 
is  then  cemented  solidly  to  the  foundation 
with  a  glue  or  cement,  and  is  weighted 
down  with  innumerable  iron  weights  and 
bags  of  cement  while  the  cement  is  set- 
ting. 

After  the  work  is  completed  the  floor 
is  perfectly  true,  without  wrinkles,  and 
does  not  give  out  the  objectionable  hollow 
sound  heard  when  walking  on  linoleum 
which  is  only  tacked  down.  Such  lino- 
leum costs  approximately  15  cents  per 
square  foot  cemented  in  place,  and  also 
requires  a  trowel-dressed  Portland  cement 
foundation,  so  that,  if  the  construction  is 
reinforced  concrete,  an  additional  charge 
of  5  cents  per  square  foot  over  and  above 
the  cost  of  the  structure  must  be  paid,  and 
if  the  building  is  of  hollow  tile  construction, 
an  additional  cost  of  9  cents  and  upward 
per  square  foot  must  be  added.  Inas- 
much as  the  so-called  sanitary  cove  at  the 
intersection  of  the  floor  with  the  walls  is 
desirable,  an  artificial  marble  or  magnesia- 
cement  baseboard  and  cove  should  be 
used  (Fig.  15).  Attempts  have  been  made 
to  cover  a  cement  cove  with  the  floor  linoleum,  curving  this  to  the  cement  upward 
to  a  steel  corner  bead,  forming  the  division  between  the  plastered  wall  and  the 
floor  linoleum.  This  could  be  done  fairly  well  adjoining  the  straight  walls,  but  it 
is  unsatisfactory  in  both  re-entrant  and  salient  angles.  It  will  be  seen  that  the 
salient  angles  must  be  filled  with  a  small  patch  of  linoleum,  or  a  cement  such  as 
magnesia-cement,  but  the  result  is  not  as  perfect  a  piece  of  work  as  a  combination 
of  linoleum  floor  and  artificial  marble  or  magnesia-cement  baseboards,  as  shown  in 
Fig.  16. 

There  is  a  plastic  linoleum  recently  come  on  the  market  which  promises  a  good 
deal  as  a  substitute  for  "battleship."    The  floors  of  the  new  New  York  Post  Graduate 


Fig.  15, 


-Section  through   tile  base  and 
linoleum  floor. 


DKTAILS    OF    STIU'CTl'ItK 


63 


School  Hospital  arc  made  almost  exclusively  of  it,  and  the  effect  is  very  attractive. 
It  is  simply  a  composition  identical  with  "  battleship  "  linoleum,  the  only  difference 
being  that  the  mixture  is  made  up  like  any  concrete  at  the  time  and  place  where  it 
is  to  be  used.  It  requires  exceedingly  careful  troweling  if  it  is  to  look  well.  It 
can  be  made  up  practically  in  any  solid  color.  In  the  same  hospital  the  labora- 
tory work-table  and  bench-tops  are  of  the  same  material.  It  has  hardly  been  in 
use  long  enough  anywhere  to  tell  whether  it  is  to  be  a  permanent  form  of  flooring. 
McKim,  Mead,  and  White,  the  New  York  architects,  think  well  of  it. 

Portland  cement  does  not  make  a  satisfactory  floor  except  when  special  mate- 
rials and  special  workmanship  are  applied.  When  the  troweling  has  been  perfect, 
and  continued  to  the  extent  that  the  surface  is  glazed,  the  softer  particles  will 
soon  wear  away  at  doorways  and  other  much  traveled  places,  so  that  the  harder 
grains  of  sand  will  project  and  show  a  surface  similar  to  sandpaper,  and  these  por- 
tions will  soon  have  a  different  texture  and  color  from  the  floor  at  walls  and  under 


LlNOL-EIUM         F=l_OOfZ.. 

rT6M  PORTAKy    OBDU N O. 


Fig.  16. — Steel  corner  plate  between  plaster  of  wall  and  composition  base. 

tables  and  beds  and  other  pieces  of  furniture.  Portland  cement  is  not  hard  enough 
uniformly  to  resist  hospital  wear.  Such  floors  can  be  given  a  finishing  of  special 
cement  floor  fillers  of  solid  colors — Pompeiian  red,  sage  green,  deep  buff,  and  gray — 
and  if  the  cement  has  been  troweled  with  great  care,  to  bring  it  to  a  true  smooth 
surface,  these  colorings  will  produce  a  floor  of  good  appearance,  but,  inasmuch  as 
the  finish  is  practically  on  the  surface,  it,  will  not  last  much  longer  than  the  var- 
nished and  painted  surfaces  of  wood,  and  must  be  renewed  from  time  to  time. 

Such  floors  are  quite  serviceable  for  rooms  which  do  not  receive  much  usage,  as 
trunk-rooms,  patients'  locker-rooms,  morgues,  and  small  chapels,  used  only  for 
funeral  services.  White  Portland  cement  can  be  obtained,  and  if  white  sand  is 
used  a  nice  appearing  floor  can  be  obtained  at  a  comparatively  low  cost,  but  all 
monolithic  floors  of  Portland  cement  and  Terrazzo  have  the  disadvantage  of  crack- 
ing in  unexpected  places  and  in  unexpected  directions.  This  is  probably  due  to  the 
different  ratios  of  contraction  between  the  floor  and  the  substructure  or  to  a  varia- 


64  HOSPITAL    ARCHITECTURE 

tion  in  the  settlement  of  the  building.  Portland  cement  is  not  elastic  like  asphalt 
or  wood  floors;  it  is  more  like  glass,  and  when  pressure  is  exerted  it  will  break. 
Inasmuch  as  Terrazzo  floors  are  only  Portland  cement  floors  with  chips  of  marble 
used  as  the  aggregate  of  the  surface,  such  floors  crack  in  a  similar  manner  to  cement 
floors.  Cement  floors  can  be  laid  in  squares,  and  Terrazzo  floors  should  be  divided 
into  small  fields  by  the  use  of  strips  of  marble,  so  that  if  there  is  a  tendency  to 
crack  it  will  occur  in  these  joints  or  along  these  strips,  since  they  offer  the  least 
resistance.  All  floors  of  the  tile  form  have  the  advantage  over  the  Terrazzo  of 
dividing  the  shrinkage  or  cracking  along  the  many  joints  in  an  irregular  maimer,  so 
that  cracks  are  seldom  noticeable  in  floors  made  of  tiles. 

Terrazzo  mosaic  floors  cost  approximately  25  cents  per  square  foot,  and  the 
cove  bases  can  be  laid  monolithically  with  such  floors.  The  plinths  for  casings, 
steps,  and  all  kinds  of  projections,  and  the  variation  in  the  wall  or  floor  surfaces  can 
be  easily  made  with  the  floor  and  the  junctions  coved  together  at  a  comparatively 
low  expense.  These  floors  can  be  ground  to  fairly  smooth  surfaces  by  rubbing  with 
sandstone  blocks,  and  portions  which  it  is  desired  to  polish  can  be  polished  with 
electric  polishing  machines.  It  is  rather  difficult  to  run  the  bases  true  against  the 
wall  in  place,  and  the  better  contractors  prefer  to  make  the  cove  bases  and  plinth 
blocks  in  molds  in  their  shops  and  there  grind  the  edges  straight  on  rubbing  beds, 
rub  and  polish  the  cove  by  machinery,  and  set  these  against  the  wall  on  the  floor 
before  laying  the  Terrazzo  floor. 

The  mosaic  floors  cost  considerably  more  than  other  floors  described,  and  are 
usually  used  only  in  the  portions  of  hospitals  which  are  intended  to  be  more  orna- 
mental, such  as  the  vestibules,  entrances,  and  chapels.  There  are  marble  mosaic 
floors  and  ceramic  mosaic  floors,  and  these  cost  from  55  cents  a  square  foot  upward. 
The  marble  mosaic  floors  are  more  expensive  and  more  beautiful  in  coloring,  the 
colors  being  softer  and  blending  together  better  than  the  opaque  pottery  colors 
used  in  the  ceramic  material.  The  cracks  mentioned  in  connection  with  Ter- 
razzo are  also  frequently  noticeable  in  marble  or  ceramic  mosaic  floors,  and  are 
due  to  unequal  settling  of  the  building  and  different  ratios  of  contraction  between 
the  floor  and  the  substructure.  Coved  bases  of  marble,  glazed  tile,  artificial 
marble,  or  magnesia-cement  can  be  used  in  connection  with  such  floors. 

Chemical  solutions  and  scrubbing  in  operating-  and  dressing-rooms  in  time 
destroy  these  floors  by  action  on  the  Portland  cement  in  their  composition. 

A  kind  of  flooring  related  to  Terrazzo  and  marble  mosaic  is  called  tutti  colori — 
or  many  colors.  It  is  made  by  scattering  the  colored  marble  chips  used  in  making 
marble  mosaic  flooring  indiscriminately  into  a  cement  field  so  that  the  pieces 
fit  together  irregularly;  this  is  rubbed  with  rubbing  stones  similar  to  Terrazzo,  and 
any  of  the  forms  of  base  described  can  be  used.  Tutti  colori  costs  about  35  cents 
a  square  foot,  and  has  the  same  faults  as  Terrazzo.  Artificial  marble  tiles  are  very 
durable,  satisfactory,  and  economic  floors,  suitable  for  kitchens,  pantries,  toilet- 
rooms,  and  the  like.  These  tiles  are  made  about  1  inch  in  thickness,  either  square, 
hexagonal,  or  oblong,  in  hydraulic  machinery.  They  have  a  wearing  surface  of 
colored  marble  chips  and  a  backing  of  Portland  cement  and  screened  stone.  These 
tiles  are  about  9  inches  square,  and  allowed  to  set  under  favorable  conditions  so 
the  cement  becomes  dense  and  hard.  They  are  then  ground  on  a  rubbing  bed  in 
the  shop  and  set  in  the  building  similar  to  any  other  form  of  tile.  They  can  be 
made  in  any  coloring  and  any  design.  Some  of  these  are  pleasing  for  use  in  an  en- 
trance hall.  Such  floors-cost  about  42  cents  per  square  foot,  and  the  bases,  5  inches 
high,  about  60  cents  per  lineal  foot,  and  have  the  advantage  of  not  showing  cracks, 
of  being  truer  and  denser  than  Terrazzo.     Coved  bases,  plinths,  and  stairs  are  made 


DETAILS   OF   STRUCTURE  65 

in  tlic  same  manner  in  the  shop,  and  the  walls  and  partitions  should  be  prepared 
to  receive  them  in  the  same  manner  as  described  fur  magnesia-cemenl  floors:  a 
design  for  stairs  made  of  polished  artificial  marble  of  this  kind  is  illustrated  in 
the  section  describing  stairs.  Such  flooring,  used  as  a  border  in  corridors  with 
coved  base  and  plinths  of  the  same  material,  and  a  runner  strip  5  or  6  feel  wide 
down  the  center  of  the  corridor,  made  by  laying  a  smooth  cement  floor  about  | 
inch  lower  than  the  surface  of  the  artificial  marble  tiles,  and  filling  the  runner 
Strip  with  "battleship"  linoleum  cemented  into  place,  will  make  almost  an  ideal 
corridor  floor. 

Anything  harder  than  linoleum,  cork  carpet,  rubber,  or  cork  is  too  noisy  for  a 
corridor. 

The  well-known  encaustic  tile  floors  cost  about  45  cents  per  square  foot,  but  are 
little  used  at  the  present  time,  and  do  not  appear  to  be  in  favor,  according  to  the 
passing  fashion  of  the  day.  These  tiles  are  made  in  pleasing  colors,  but  they 
break  quite  easily  and  sometimes  separate  from  the  foundation,  so  that  walking 
over  a  defective  tile  floor  produces  a  rattling  sound.  This  is  probably  due  more 
to  improper  laying  than  any  fault  in  the  material.  If  the  tiles  are  well  soaked, 
anil  genuine  Portland  cement  used,  such  tiles  ought  to  have  a  foundation  so  firm 
that  they  cannot  break  under  ordinary  usage  or  become  loose,  but  there  is  no  tile 
cove  made  which  has  not  the  objection  of  being  in  small  pieces,  so  that  an  artificial 
marble  or  magnesia-cement  base  should  be  used  in  connection  with  such  tile. 

Ceramic  tiles  are  very  dense,  flinty  pottery,  and  absolutely  impervious.  The 
surface  is  slightly  gritty,  so  that  they  are  not  slippery,  and  wdren  used  in  the  larger 
sizes  such  a  floor  is  one  of  the  best  for  operating-rooms.  These  tiles  can  be  ob- 
tained in  2-,  3-,  4-,  and  5-inch  hexagons,  also  in  squares  of  the  same  dimensions. 
The  one  fault  of  this  kind  of  flooring  is  that  the  tiles  must  be  set  in  a  pervious  mor- 
tar joint,  which  forms  a  network  over  the  entire  floor  and  which  cannot  resist 
scrubbing.  In  time  these  joints  will  be  considerably  lower  than  the  surface  of  the 
tile,  become  dark,  and  sometimes  black.  Either  artificial  marble  coves  and  plinths 
or  genuine  marble  or  magnesia-cement  should  be  used  in  connection  with  such 
floor. 

One-inch  thick  white  glass  can  be  obtained  and  has  been  used  for  operating- 
room  floors.  This  material  is  ground  on  the  rubbing  bed,  similar  to  plate  glass,  to 
a  true,  slightly  gritty  surface,  and  is  beautiful  in  appearance.  The  coves  and 
plinth  blocks  can  be  made  of  the  same  material  and  these  can  be  polished  if  de- 
sired. The  material  costs  approximately  S2  per  square  foot.  It  is  not  advisable 
to  lay  pieces  larger  than  18  by  30  inches  on  the  floor,  for  it  becomes  too  difficult 
to  bed  large  pieces  so  perfectly  that  there  will  not  be  places  without  bedding.  It 
is  obvious  that  a  piece  which  is  not  perfectly  bedded  will  crack  very  easily. 

Slate,  at  about  70  cents  per  square  loot,  white  Italian  marble,  at  80  cents  per 
square  foot,  gray  Tennessee  marble,  at  90  cents  per  square  foot,  make  good  service- 
able floors,  and  the  sizes  of  the  pieces  are  subject  to  the  same  limit  as  heavy  glass. 
The  slate  is  very  dense  and  impervious,  but  its  dark  appearance  is  not  suitable  for 
an  operating  department.  The  Italian  marble  is  not  sufficiently  impervious.  The 
light  gray  or  pink  Tennessee  marble  is  very  dense  and  a  very  serviceable  floor. 
Its  color  is  such  that  it  does  not  show  the  tracking  of  footsteps  readily,  and  may  lie 
objectionable  in  a  hospital  for  this  reason. 

Rubber  floors  cannot  lie  obtained  for  lcs>  than  Si  per  square  foot,  except  where 
very  large  quantities  are  used,  and  this  kind  of  flooring  requires  a  special  cement 
foundation  similar  to  that  described  for  linoleum,  so  that  its  cosl  is  almost  pro- 
hibitive  in  a  hospital  of  moderate  cost.     The  rubber  comes  in  tiles  usually  of  an 


66  HOSPITAL    ARCHITECTURE 

interlocking  pattern,  in  a  variety  of  opaque  colors,  and  can  be  laid  in  pleasing 
patterns,  but  rubber  coves  are  not  good,  and  it  will  be  necessary  to  use  one  of  the 
forms  of  cove  described  with  the  tile  floors. 

Compressed  cork  is  one  of  the  newest  materials  on  the  market,  has  a  very 
pleasing,  warm  color,  similar  to  English  oak  or  tobacco  brown.  It  is  elastic  and 
noiseless,  and  the  makers  claim  that  it  will  not  wear  out.  It  must  be  laid  on  a 
cement  special  foundation,  composed  of  sawdust  and  Portland  cement,  which  costs 
about  8  or  9  cents  per  square  foot,  depending  on  the  thickness.  The  cork  floor- 
ing can  be  obtained  in  different  sized  squares  3  by  3  inches  and  9  by  9  inches  and 
in  different  shades,  so  that  it  can  be  laid  in  a  variety  of  patterns.  The  manu- 
facturers also  offer  a  cork  base  cove  and  plinth  blocks,  and  show  how  it  can  be  used 
for  the  treads  of  stairs,  and,  inasmuch  as  it  is  not  slippery,  it  makes  an  excellent 
stair  tread.  The  material  in  large  quantities  costs  about  85  cents  per  square  foot. 
Its  chief  disadvantage  is  that  it  is  probably  not  sufficiently  impervious  to  septic 
matter  and  micro-organisms,  as  most  other  floorings. 

Magnesia  Composition  Floors. — These  floors  are  known  under  various  trade 
names,  such  as  Asbestolith,  Karbolith,  Monolith,  Flexolith,  Magnasite,  and  Dolo- 
ment.  They  are  composed  principally  of  pure  ground  magnesia  and  other  ingre- 
dients, which  are  trade  secrets.  Some  makers  use  hardwood  sawdust,  others  short 
fiber  asbestos  or  quartz  sand,  and  possibly  many  other  materials.  The  flooring, 
when  well  laid  and  properly  maintained,  has  almost  every  one  of  the  requisite 
qualities  of  a  good  floor.  It  is  applied  in  the  plastic  state,  so  that  it  is  jointless. 
The  baseboard  and  cove  can  be  made  monolithic  with  the  floor.  The  material 
can  be  applied  around  bases  of  all  pieces  of  furniture,  columns,  and  into  plinths  for 
door  trim.  If  the  mixture  is  not  too  rich  or  too  hard  in  itself  the  flooring  has  some 
elasticity,  is  not  as  noisy  as  wood,  tile  or  mosaic,  is  less  slippery  than  these,  can 
be  colored  and  be  pleasing  in  appearance,  and,  inasmuch  as  there  are  no  joints 
or  crevices,  can  be  easily  cleaned. 

The  completed  flooring  should  be  treated  with  an  oil  in  order  to  preserve  the 
depth  of  coloring  and  finish.  The  oil  also  protects  the  material  from  water.  The 
material  is  not  suitable  for  places  where  water  is  used  freely,  or  where  water  is 
allowed  to  drop  on  it,  as  in  the  douche  room  of  the  hydrotherapeutic  department; 
it  can  be  easily  cleaned  by  wiping  with  a  cloth  moistened  in  tepid  water  and  a  light 
soapsud,  but  should  not  be  scrubbed  with  a  brush,  for  the  stiff  bristles  will  loosen 
particles  of  the  surface  in  time  and  change  the  floor  from  a  smooth  to  a  pitted 
surface.  The  material  is  probably  not  suited  for  operating-  and  dressing-rooms 
on  account  of  the  use  of  chemical  solutions  and  the  necessary  frequent  scrubbing. 
The  efficiency  and  durability  of  a  magnesia  composition  floor  depends  not  only 
on  the  quality  of  the  material  used,  but  on  the  most  careful  proportioning  of  these 
materials  and  perfect  troweling.  The  work  must  be  laid  by  mechanics  skilled 
in  this  class  of  work,  and  these  are  difficult  to  find.  Workers  of  Portland  cement 
believe  themselves  capable  of  executing  such  floor  work,  but  they  require  consid- 
erable practice  before  becoming  skilled.  If  the  troweling  is  not  carefully  done 
and  properly  executed,  the  floor  will  have  a  very  wavy  appearance  and  a  surface 
of  unequal  texture.  The  material  appears  to  be  so  easily  used  and  applied  that 
many  inexperienced  persons  are  offering  to-day  this  class  of  work,  with  the  con- 
sequent result  that  there  have  been  many  more  failures  than  successes.  Some 
of  these  floors  have  shrunken  to  such  an  extent  that  they  were  obliged  to  crack, 
loosen  themselves  from  the  foundations  into  irregular-shaped  pieces,  and  con- 
sequently rattle  and  rock  when  walked  upon.  Others  have  been  so  soft  that  the 
floors  disappear  in  patches,  exposing  the  concrete  foundation.     When  such  work 


dicta i ls  of  stricture 


G7 


is  required  it  should  be  given  only  to  established  concerns,  having  had  years  of 
experience  and  successful  work  for  satisfied  customers,  to  which  prospective 
customers  can  be  referred,  and,  in  the  case  of  firms  meeting  such  requirements,  it 
would  be  well  to  exact  a  carefully  written  guarantee  for  not  less  than  eighteen 
months. 

Magnesia  composition  floors  are  practically  well  adapted  for  use  in  buildings 
of  reinforced  concrete  construction,  inasmuch  as  the  floor  construction  proper 
serves  as  a  foundation  for  the  composition  without  special  finishing  and  troweling 
of  the  concrete  surface,  such  as  must  be  supplied  when  linoleum  or  cemented  wood 
flooring  is  used.  The  cost  of  magnesia  composition  floors  approximates  25  cents 
per  square  foot,  and  coved  8-inch  high  baseboards  approximately  the  same  amount 
per  lineal  foot.  Measurements  should  be  taken  from  wall  to  wall  for  the  floor- 
ing and  the  baseboards  added  as  a  separate  item.  The  material  can  be  laid  in 
patterns  and  borders  by  the  use  of  brass  dividing  strips,  filling  the  various  spaces 
with  different  colored  or  tinted  composition. 

BASE  COVES 

The  several  kinds  of  flooring  described  have  each  a  base  eove  most  suited  for 
the  purpose.  It  is  recognized  that  any  surface  having  a  horizontal  projection  will 
catch  more  dust  than  vertical  surfaces.  Also  that  re-entrant  angles  require  con- 
siderable labor  to  remove  dust  from  them,  so  that  the  omission  of  re-entrant  angles 


Fig.  17. — An  internal  angle  showing  a  coved  wooden  base  flush  with  floor  and  plaster.  Xotiee 
the  corner  block  which  must  conform  to  the  radius  of  the  plastered  corner  coves,  and  is  made  by 
<iuurlcring  a  turned  wooden  cup. 


ami  horizontally  projecting  surfaces  from  the  walls  of  a  room  reduces  the  labor 
of  cleansing.  The  old  forms  of  projecting  baseboards  offered  a  lodging  place  For 
dust  on  each  one  of  the  horizontal  or  slanting  surfaces  of  the  molding,  and  the 
junction  with  the  floor  formed  an  internal  angle  difficult  to  clean,  and  the  hard 
Scrubbing  required  thereby  removed  the  finish  from  the  baseboard.     A  curved 


HOSPITAL    ARCHITECTURE 


Kg.  18. — Artificial  marble  base  fitted  to  rolled  steel  combined  frame  and  door  casings 


k\ 


Elevation  of  glazed  tile  jamb  &  base  with  wood  jamb  asove 


c 


DETAIL    SECTION    THROUGH    GLAZED    TILE    JAMB    PLINTH 

Fig.  19. 


DKTAILS    OF"    STUITTI'RE  69 

surface  joining  the  floor  with  the  wall  is  easily  produced  in  cement  and  was  prob- 
ably firsl  used  with  this  material.  It,  was  an  easy  step  to  using  Terrazzo  mosaic 
in  the  same  manner,  but  always  with  a  projecting  horizontal  surface.  The  cove 
base  was  omitted  in  good  work,  but  by  nailing  the  cove  on  the  floor  and  against 
the  floor,  making  not  only  a  horizontal  projecting  surface,  but  also  an  additional 
internal  angle  at  the  floor.  All  of  these  objections  are  obviated  in  modern  work, 
and  bases  are  flush  with  the  wall  and  flush  with  the  flooring.  This  can  be  done  in 
woodwork,  as  shown  in  Fig.  17.  A  temporary  wooden  ground  is  placed  against  the 
wall  for  the  plasterer,  and  removed  when  the  carpenter  is  ready  to  set  the  coved 
wooden  base.  The  same  procedure  can  be  followed  wherever  monolithic  Terrazzo 
or  shop-made  artificial  marble  or  natural  marble,  glass,  tile,  or  cork  bases  are 
used  (Fig.  18).  When  it  is  desired  to  use  Portland  cement  or  monolithic  Terrazzo 
or  magnesia  composition  bases  it  is  best  to  have  the  lathers  place  a  steel  corner 
plate  around  the  room  at  the  top  of  the  base  line,  and  permit  this  steel  corner  plate 
to  remain  in  place  between  the  plaster  and  the  Portland  cement  or  magnesia  com- 
position base,  as  shown  in  the  illustration.  The  details  for  joining  the  vertical 
cover  of  the  plaster  walls  and  the  horizontal  coves  of  the  floor  can  be  worked  out 
easily  by  the  architect.  All  cove  bases  should  go  to  a  full  height  of  8  or  9  inches 
above  the  surface  of  the  floor,  so  that  in  mopping  and  scrubbing  the  walls  will  not 
be  stained  (Fig.  19). 

STAIRS  IN  THE  HOSPITAL 

In  cities  the  number  and  width  of  stairs  are  usually  governed  by  ordinances, 
but,  in  any  event,  it  is  advisable  to  place  stairs  at  all  extremities  of  the  building, 
for,  notwithstanding  that  a  building  may  be  fireproof,  smoke  or  an  explosion  may 
cause  a  panic,  and  stairs  should  be  so  placed  that  persons  can  escape  by  running 
from  the  fire.  If  the  building  is  long  and  narrow  and  the  central  stair  is  a 
requisite  for  purposes  of  administration,  there  should  at  least  be  porches  con- 
nected by  stairways  at  the  ends. 

Almost  every  modified  block  or  modified  pavilion  plan  affords  a  number  of 
corners  not  suited  for  room  or  ward  purposes.  The  stairs  can  usually  be  placed  in 
such  spaces  to  good  advantage  to  the  plan  and  illuminated  by  skylights  if  the  well 
holes  are  not  too  restricted. 

Every  stairway  with  the  exception  of  monumental  stairs  should  be  enclosed  to 
confine  noise  and  to  make  them  safe  in  the  event  of  fire,  and  the  enclosure  should 
generally  be  of  fireproof  construction,  and  it  is  more  necessary  that  the  stairs  be 
enclosed  in  fireproof  construction  in  buildings  of  ordinary  construction  than  in 
those  of  fireproof  construction. 

More  privacy  is  also  assumed  by  enclosing  stairs,  and  assists  in  control  of 
visitors. 

The  doors  leading  to  such  stairways  should  be  of  heavy  wood  or  metal  clad,  easy 
of  operation,  and  closed  by  dour  checks  and  springs.  The  base  of  each  stairway 
should  have  a  door  leading  directly  to  the  exterior  and  close  to  the  ground.  It  is 
best  to  have  the  stairways  leading  to  the  basement  in  separate  enclosures,  and  that 
the  Stairways  to  the  upper  stories  do  nut  extend  into  the  basement,  inasmuch  as 
fire  is  more  likely  to  originate  in  the  basement  and  may  communicate  t<>  the  upper 
floors  through  a  stairway. 

Stairs  of  wood  are  used  only  in  comparatively  small  buildings,  and  it  is 
more  difficult  to  keep  up  their  appearance  than  if  is  that  of  floors.  ( lonsequently, 
stairs  are  usually  built  of  incombustible  material  which  may  lie  molded  in  the  mo-i 
desirable  shapes  and  requires  little  or  no  expense  for  up-keep.     Cast-iron  and 


70 


HOSPITAL    ARCHITECTURE 


wrought-iron  stairs  or  a  combination  of  these  are  comparatively  low  in  price,  but 
the  treads  become  slippery  quickly  and  they  are  exceedingly  noisy.  Such  treads 
can  be  covered  with  linoleum  glued  to  the  treads  and  finished  with  a  brass  nosing, 
but  the  junction  with  the  strings  and  risers  form  dirt-catching  recesses. 

The  combination  of  iron  supports  with  slate,  marble,  or  magnesia  cement  treads 
are  better,  but  they  also  have  deeply  recessed  angles  in  the  corners.  ■  Polished 
artificial  marble  made  in  the  same  manner  as  described  for  floor  surfacing  is  one  of 
the  best  and  most  economic  stair  materials.  If  used  in  combination  with  solid 
masonry  walls  such  stairs  can  be  self-supporting  without  the  use  of  iron,  except 
such  is  used  for  the  balustrade.      Figure  20  illustrates  such  a  stairway.      If  solid 


Fig.  20. — Scale  drawing  and  details  of  reinforced  concrete  stairs  with  safety  tread  nosings  and 
magnesia  cement  treads,  risers  and  strings  joined  by  coves  in  the  angles. 


masonry  walls  cannot  be  built,  such  a  stair  may  be  supported  on  steel  supports  or 
a  reinforced  concrete  slab,  which  will  require  a  plastered  finish  on  the  soffit,  which 
is  good,  but  not  as  attractive  as  a  polished  artificial  marble  surface.  This  material 
is  easily  prepared  to  receive  specially  made  antislip  nosings.  Such  nosings  are 
usually  made  of  a  combination  of  lead  and  steel,  or  brass,  or  carborundum;  all  of 
these  are  both  sightly  and  effective.  On  account  of  the  cost  these  safety  nosings 
are  generally  used  in  strips  only  about  3^  inches  wide,  countersunk  into  the  stair 
tread.  Stairs  formed  of  reinforced  concrete,  plastered  on  the  soffit,  covered  with 
magnesia  cement  on  the  treads,  risers,  and  strings,  and  provided  with  a  metal 
safety  tread  are  economic,  of  very  good  appearance,  solid,  practically  noiseless, 
and  easy  to  clean,  for  all  angles  and  corners  can  be  coved. 


DETAILS    OF    STRUCTURE  71 

The  landing  railings  and  stair  railings  should  ho  higher  than  in  the  dwelling- 
houses  and  other  buildings.  The  rule  for  dwellings  is  to  make  the  top  of  the  railing 
28  inches  above  the  step  at  the  nosing,  but  in  a  hospital  the  railing  should  be  6  or 
8  inches  high,  and  at  floor  landings  and  other  landings  railings  should  beat  least  4 
feet  high.  In  a  children's  hospital  and  in  asylums  it  would  be  best  to  have  stair- 
ways with  solid  masonry  piers  between  the  flights  from  the  bottom  to  the  top  or 
balustrades  about  (5  feet  in  height  with  wooden  hand-rails  on  metal  supports  at  a 
convenient  height. 

PARTITIONS 

Inasmuch  as  it  is  expected  that  only  hospitals  of  fireproof  construction  shall 
be  erected,  combustible  partitions  will  not  be  described.  The  ordinary  forms  of 
incombustible  partitions  are:  first,  gypsum  blocks,  3,  4,  and  5  inches  in  thick- 
ness and  upward;  second,  hollow  fire-clay  tiles,  3  inches  in  thickness  and  upward; 
so-called  solid  plaster  partitions,  1|  inches  and  upward  in  thickness;  metal  stud 
and  metal  lath-and-plaster  partitions;  gypsum  stud  and  gypsum  board  partitions. 
Gypsum  block  partitions  are  sometimes  known  as  mackolite.  The  blocks  are  usu- 
ally made  1  foot  wide  and  4  feet  long,  of  varying  thicknesses,  with  several  round 
longitudinal  perforations  reinforced  with  lath  or  rods,  and  made  of  gypsum.  These 
partitions  are  good  insulators  against  sound  and  heat,  and  cost,  with  plastering 
on  both  sides,  approximately  17  cents  per  square  foot.  The  hollow  clay  tile  parti- 
tions are  made  1  foot  square,  with  perforations  or  rectangular  cross-sections  through 
them  and  the  wall  of  tile  about  f-  to  f-inch  thick.  These  tiles  are  burned  in  kilns 
similar  to  brick  and  terra-cotta,  and  a  3-inch  partition  plastered  on  both  sides 
costs  approximately  19  cents  per  square  foot. 

Thoroughly  burned  clay  tiles  do  not  disintegrate  in  moist  or  damp  places,  and 
are  suitable  for  use  in  situations  where  gypsum  blocks  are  less  satisfactory,  viz.: 
laundries,  steam-rooms,  sterilizing-rooms,  boiler-rooms,  and  in  basements.  Where 
plastering  is  not  required,  and  whitewashing  will  be  a  sufficient  finish,  clay  tiles 
are  more  suitable  than  the  other  partition  described,  and  they  can  be  obtained 
unscored,  i.  e.,  smooth,  for  this  purpose  at  a  cost  of  about  9  cents  per  square  foot 
erected. 

Solid  plaster  partitions  are  made  by  using  f-  or  1-inch  steel  channel  bars,  stuck 
into  holes  in  the  floor  and  ceiling,  and  there  secured  by  screws  or  staples.  These  are 
placed  about  12  inches  center  to  center,  and  a  wire  cloth,  expanded  metal,  or  other 
metal  lath  is  secured  to  these  studs  by  soft  iron  wire  (Fig.  21).  The  metal  lath 
is  then  given  a  thin  coat  of  mortar.  This  upon  setting  has  stiffened  the  partition 
considerably,  and  additional  coats  are  then  applied  on  each  side  and  brought  to  a 
thickness  of  almost  li  inches  for  the  thinnest  kinds.  When  this  is  done  the  parti- 
tion is  so  stiff  that  the  journeyman  can  use  the  necessary  pressure  to  produce 
fairly  true  surfaces.  These  are  then  given  thin  coats  or  a  finishing  coat  of  lime, 
putty,  or  plaster  of  Paris.  Such  partitions  cost  about  17  cents  per  square  foot. 
Inasmuch  as  electric  outlets  must  have  steel  boxes,  it  is  difficult  to  enclose  these 
in  solid  plaster  partitions  of  only  1 J  inches  in  thickness,  and  it  is  necessary  to  make 
them  2  inches  in  thickness  to  conceal  the  box,  and  then  it  is  further  necessary  to 
use  a  special  mat-board  for  the  switch  or  a  flush  electric  socket.  These  parti- 
tions have  a  lower  sound-insulating  value  than  any  of  the  other  partitions  described, 
but  they  have  been  used  in  a  number  of  hospitals  and  have  given  fair  satisfaction. 
There  are  partitions  in  which  metal  studs,  made  of  specially  formed  sheet  metal, 
are  employed,  and  these  studs  have  spike-like  projections  over  which  the  metal 
lath  can  be  stretched  and  secured  by  a  blow  with  a  hammer.     Such  partitions 


72 


HOSPITAL    ARCHITECTURE 


have  metal  lath  on  both  sides,  which  must  be  plastered  with  three  coats  of  plaster, 
and,  consequently,  cost  fully  as  much  as  a  gypsum  block  or  hollow  clay  tile  parti- 
tion, but  they  have  the  advantage  of  a  continuous  air  space,  and,  therefore,  a  higher 
sound-insulating  value.  These  partitions  cost  approximately  21|  cents  per  square 
foot  plastered  complete. 

There  are  other  partitions  on  the  market,  but  not  in  very  common  use.  One 
of  these  consists  of  strips  of  gypsum  which  are  set  upright  similar  to  wooden  stud- 
ding, and  to  which  1-inch  thick  boards  of  gypsum  blocks  and  jute  are  secured 
on  both  sides  by  plaster  of  Paris.     In  some  localities  these  can  probably  be  ob- 


Fig.  21. — An  elevation  of  a  solid  cement  plaster  closet  stall  partition.  Notice  the  iron  door- 
post, steel  top  and  bottom  rails,  vertical  steel  channels,  wire  bath  or  expanded  metal  wired  to  the 
channels  and  to  plaster  surfaces.  The  plaster  surfaces  are  to  be  coved  into  the  walls  at  the  back 
of  the  stalls. 


tained  for  less  money  than  the  gypsum  blocks,  and,  inasmuch  as  they  have  air 
spaces,  their  sound-insulating  value  is  fair. 

Partitions  are  sometimes  made  of  well-burned  steam  boiler  cinders  and  plaster 
of  Paris  in  the  form  of  blocks,  similar  to  gypsum  block.  This  material  can  be  made 
by  mechanics  on  the  site,  and,  if  carefully  made  and  properly  dried  out,  makes  a 
good  and  economic  partition.  Partitions  are  sometimes  made  by  stretching 
wires  vertically,  horizontally,  and  diagonally  in  two  directions,  approximately  1 
foot  apart ;  board  forms  about  3  feet  high  on  each  side  of  these  wires  are  set  so  that 
a  space  of  2  to  2k  inches  will  intervene  between  the  board  forms,  and  these  forms  are 
then  poured  full  of  mortar  composed  of  plaster  of  Paris,  sand,  and  cinders.  As 
soon  as  the  mass  has  set  sufficiently  to  remain  in  place  the  forms  are  raised,  and 


DETAILS   OF   STRICTURE  !'.*, 

the  same  procedure  :is  before  is  continued  until  the  partition  is  built  close  to  the 
ceiling.  It  is  obvious  that  a  small  strip  near  the  ceiling  must  be  filled  in  by  a  trowel 
from  one  side.  In  a  building  which  need  not  be  strictly  fireproof  it  is  permissible 
to  use  2  by  4  inch  wooden  studding,  placed  12  inches  on  centers  and  lathed  on 
both  sides  with  wire  lath,  each  plastered  with  three  coats  of  mortar.  Such  parti- 
tions cost  a  little  more  than  the  solid  plaster  partitions,  but  are  somewhat  more 
sound-proof.  If  particularly  sound-proof  partitions  are  required  for  special  cases, 
it  is  advisable  to  build  these  double  and  with  unbroken  air  spaces.  The  insulation 
may  be  increased  by  applying  1-inch  cork  boards  against  one  of  the  partitions. 
The  cork  board  can  be  in  the  space  between  the  two  or  it  can  be  inside  of  the  inner 
partition,  for  it  can  be  plastered  with  Portland  cement  fully  as  readily  as  any 
masonry  surface. 

It  is  obvious  that  to  obtain  a  sound-proof  room  the  room  must  have  no  rigid 
connection  with  any  other  part  of  the  building,  and  any  rigid  connection  from  one 
portion  of  a  hollow  partition  across  the  air  space  will  carry  some  sound;  likewise, 
sound  will  be  carried  through  the  floor  underneath  the  partition  or  through  the 
ceiling  over  the  partition,  so  that  this  desirable  quality  can  only  be  obtained  in 
degrees  proportionate  to  the  increased  expense.  Some  builders  have  advocated  the 
use  of  rubber  blocks  under  special  sleepers  and  the  joining  of  the  two  separate 
and  distinct  door  frames,  one  in  the  inner  partition  and  one  in  the  outer  partition, 
by  flexible  rubber  strips.  This  can  unquestionably  be  done  and  a  sound-proof 
room  can  be  obtained,  but  the  expense  of  doing  so  will  seldom  be  entertained  by 
any  hospital  committee. 

FURRING 

Material  built  close  to  a  wall  or  clown  from  a  ceiling  to  form  an  air  space,  to 
conceal  constructive  features  or  pipes,  or  to  give  semblance  to  constructive  forms, 
as  the  imitation  of  a  pilaster  or  a  vault,  is  termed  "furring";  as  explained  in  the 
paragraphs  on  exterior  walls,  it  is  a  necessary  device  in  northern  climates  to  pre- 
vent the  forming  of  condensation  and  to  diminish  the  loss  of  heat  through  the  outer 
walls  of  a  building. 

Some  of  the  waterproofing  liquids  on  the  market,  composed  of  bitumen  and 
water-glass,  will  seal  the  pores  on  the  inside  of  the  wall  quite  effectively,  so  thai 
plastering  can  be  applied  directly  on  the  brick,  concrete,  or  other  forms  of  masonry, 
and  the  makers  claim  almost  as  high  an  insulating  value  as  any  of  the  furrings 
described,  but  it  is  still  questionable  if  this  is  a  fact,  and  the  cost  of  applying  such 
waterproofing  and  insulating  compounds  is  almost  as  much  as  the  cost  of  furring 
the  walls. 

The  air  space  is  also  invaluable,  insomuch  that  it  provides  a  space  in  which 
pipes  of  all  kinds  can  be  placed  and  concealed,  without  making  the  laborious  pro- 
cess of  forming  or  cutting  channels  in  the  brick  tile  or  concrete  walls  compulsory. 
Such  cutting  is  not  only  expensive,  but.  often  shatters  and  weakens  a  wall  or  pier. 
Furring  is  usually  executed  with  the  same  kind  of  material  used  for  the  partitions. 

Gypsum  furring  boards  are  made  from  1  to  2  inches  in  thickness,  and  have  ribs 
formed  on  their  backs  to  obtain  a  thin  air  space.  Clay  tile  furring  is  obtained  by 
splitting  3-inch  pieces  into  two  equal  parts  along  grooves  formed  in  the  blocks 
intended  for  this  purpose,  and  made  by  the  block-making  machine  before  burning, 
resulting  in  a  1-ineh  air  space. 

\\  ire  mesh,  metal  lath,  and  expanded  metal  is  held  away  from  the  exterior  walls 
by  bands  of  crimped  steel,  which  can  be  obtained  in  varying  widths,  \  to  I  inches 

wide  being  the  mosl  suitable. 


74 


HOSPITAL    ARCHITECTURE 


Where  water-closet  soil-pipes  or  other  large  pipes  require  large  spaces,  3-inch 
blocks,  set  the  requisite  distance  away  from  the  structural  walls,  should  be  em- 
ployed. 

The  cost  of  furring  is  about  three-quarters  that  of  the  partition  and  plastering. 

WINDOW  FRAMES 

The  windows  are  of  such  a  great  importance  for  ventilating  that  they  must 
receive  special  consideration.  The  standard  window  in  the  market  is  the  one  hav- 
ing two  sliding  sash,  technically  known  as  the  double-hung  check-rail  sash  with 


EXTEEIOE.'        -INTEEIOE. 
'EUE  wv-ri  O  N  s  • 


Fig.  22. — Window  details. 


box  frame.  This  kind  of  window  has  the  advantage  of  accessibility  for  cleaning, 
and  where  a  safety  rope  is  used  the  cleaner  can  stand  on  the  outside  of  the  window 
sill  and  wash  the  window  while  it  is  closed,  but  the  window  has  several  disad- 


DETAILS   OK   STRUCTURE  40 

vantages.    One  is  that  it  does  uo1  open  the  entire  opening  of  the  window,  but  only 
half  in  hot  weather,  and  in  cold  weather  it  permits  direct  drafts. 

The  so-called  plank  frame  window,  with  hinged  or  casement  sash  swinging  inward, 
is  also  objectionable  on  account  of  the  direct  drafts  and  the  difficulty  of  applying 
an  adjuster  by  which  the  sash  can  be  set  and  held  at  any  angle.  These  objections 
also  apply  against  the  same  kind  of  a  frame  with  sash  swinging  outward,  but  such 
sash  can  be  equipped  with  satisfactory  operators,  can  be  opened  and  closed  without 
removing  the  insect  screens,  which  must  be  on  the  inside  when  the  sash  swings  out- 
ward.    Double  transom  sash  in  the  upper  part  of  a  window  will  ventilate  a  room 


-DSLTAU-sS-^  °F    THE.  "HOLDFA5T" 
CASE.nE.AJT    WIAJDOW  ADJUSTER. 

Fig.  23. — "  Holdfast  "  easement  window  adjuster. 


rapidly  without  objectionable  drafts.  Such  transoms  can  be  used  in  combina- 
tion with  double-hung  sash  for  the  lower  part  of  the  window,  but  this  is  not  advis- 
able, except  where  the  window  frames  and  the  stories  are  unusually  high.  Where 
th«y  are  to  be  used  iii  frames  and  stories  of  ordinary  height  the  lower  portion  of 
the  window  should  be  equipped  with  outward-swinging  casement  sash  (Fig.  22), 
operated  by  casement  adjusters,  such  as  the  Casement  Hardware  Co.'s  "Hold- 
fast" (Fig.  23),  or  the  Yale  and  Towne  Mfg.  Co.'s  Wilkins'  "Operator"  (Fig.  24). 
The  inside  of  the  frame  should  be  rebated  for  hinged  screens  for  summer  use 
and  inwardly  swinging  casement  sash  for  winter  use.  With  such  windows  the  cut  ire 
window  opening  can  be  used  in  summer  time. 


76 


HOSPITAL    ARCHITECTURE 


The  outer  transom  should  be  hung  on  its  upper  edge  and  swing  outward  from  the 
bottom.  The  inner  one  should  be  hinged  at  the  bottom  and  swing  inward  from 
the  top,  and  the  two  connected  by  a  friction  center  device,  which  can  be  obtained 
from  several  makers  of  hardware,  and  which  will  not  interfere  with  the  placing  of 
an  insect-screen  in  the  middle  of  the  space  between  the  two  transoms.  The  con- 
necting device  will  open  and  close  the  outer  sash  when  the  inner  one  is  similarly 
operated.  The  outer  sash,  fitting  like  an  awning,  will  protect  the  open  window  from 
rain,  and  can  be  left  open  unless  the  rain-storm  is  accompanied  by  a  very  strong 
wind.     The  inner  transom  will  deflect  air  currents  upward,  so  that  the  fresh  air 


POSITION    Of  HANDLE 
UAU3CHED, 

rr 


Fig.  24. — Details  of  the  "Wilkins"  casement  window  adjuster. 


will  be  diffused  and  not  enter  in  drafty  currents.     The  frame  and  sash  are  illus- 
trated in  Figs.  22-24. 

To  obtain  a  weather-proof  joint  between  the  edges  of  pairs  of  hinged  sash  where 
they  meet,  the  architect  must  resort  to  peculiar  detailing  of  the  woodwork,  which 
permits  the  opening  of  either  the  right-  or  left-hand  sash  in  advance  of  the  other, 
whichever  way  it  may  be  detailed;  this  can  be  avoided  by  placing  a  vertical  fixed 
piece  of  wood,  termed  a  "mullion,"  between  the  two  sash. 

WOODWORK 

Dense,  close-grained,  hard  woods  are  the  most  desirable  for  hospital  purposes. 
The  coarse-grained  woods,  such  as  oak,  ash,  and  mahogany,  must  be  filled  with  a 
mineral  filler  to  obtain  a  smooth  surface  before  they  are  otherwise  treated. 


DETAILS   OF   STRUCTURE  77 

Birch  is  the  lowest  priced  hard  wood  on  the  market  when  accepted  without 
Selection.  This  is  not  suitable  for  light  or  natural  finish  on  account  of  variations 
in  coloring.  The  greater  portion  has  an  even,  pleasing  color,  but  there  are  enough 
pieces  of  white  sap  or  a  dark-blue  sap  to  destroy  the  harmony,  and  it  is  consequently 
necessary  to  stain  such  wood,  when  it  a1  once  becomes  darker  than  is  generally 
accepted  as  suitable  for  a  hospital,  and  it  becomes  necessary,  therefore,  to  specify 
a  selected  birch,  which  costs  a  little  more.  This,  when  finished  natural,  is  very 
satisfactory,  (iuni  wood  is  rather  too  dark  for  hospital  use,  is  of  comparatively 
Milt  texture,  but  may  be  considered  in  some  instances.  Yellow  pine  is  hard,  dense, 
ami  one  of  the  best,  of  the  cheap  woods;  it  darkens,  however,  with  age  to  an  extent 
ami  to  a  tone  not  generally  pleasing.  It  can  be  stained  in  any  variety  of  stains 
except  the  lighter  ones,  so  that,  whereas  it  may  be  usable  in  the  service  portions  of 
the  hospital,  it  is  hardly  suitable  for  the  wards  and  the  rooms  used  by  patients. 

Mahogany  may  be  used,  but,  on  account  of  its  expense,  only  in  a  few  special 
private  rooms;  but  even  in  these  genuine  white  enamel  work  on  birch  would  be 
more  attractive  to  the  average  patient. 

White  enamel  work,  having  the  appearance  of  the  favorite  egg-shell  surface,  can 
be  produced  by  the  brush  without  rubbing  if  one  of  the  higher  grades  of  enamel  is 
used,  and  this  effect  can  be  obtained  by  a  comparatively  small  number  of  coats; 
in  some  instances  as  low  as  three.  Inasmuch  as  the  wood  used  should  be  hard 
enough  to  resist  some  wear  and  abrasion,  the  cheapest  kind  of  birch  may  be  used, 
and  with  three  or  four  coats  of  good  enamel  paint  such  woodwork  does  not  cost 
any  more  than  a  good  oak  or  ash. 

In  order  to  avoid  recesses  and  other  places  which  are  cleaned  only  by  the 
expenditure  of  considerable  labor,  it  has  been  the  fashion  for  the  past  fifteen  years 
to  use  only  flush  doors,  that  is,  doors  without  panels,  in  the  latest  hospital  construc- 
tion, but  these  doors  are  so  severe  in  appearance  that  they  have  a  gloomy  effect 
on  patients,  so  that  some  of  the  newer  hospitals  have  reverted  to  the  use  of  single- 
panel  doors;  it  is  not  necessary  to  do  this,  however,  for  the  flush  doors  are  veneered 
on  built-up  soft  wood  cores,  and  with  veneering  it  is  a  simple  matter  to  inlay  a 
border  line  or  lines  marking  imaginary  panels.  These  border  lines  can  be  made 
up  of  narrow  strips  of  dark  or  black  wood,  so  that  the  heavy,  severe  effect  is  removed 
at  once.  This  is  done  by  a  number  of  manufacturers  and  at  a  comparatively  small 
expense  above  the  cost  of  a  flush  door. 

Those  who  have  complained  of  the  severity  of  the  flush  panel  doors  object  to 
the  omission  of  woodwork;  in  their  opinion  the  depressing  effect  of  the  cell-like 
severity  is  much  greater  than  the  possible  deleterious  effect  of  the  few  additional 
angles  introduced  by  trimming  the  door  and  window  openings  with  wooden  facings. 
The  wooden  casings  should  be  molded  sensibly  and  with  not  too  many  quirks  and 
angles. 

Many  attempts  have  been  made  to  avoid  the  use  of  projecting  wooden  door  and 
window  casings,  but  this  has  not  been  successful  for  several  reasons,  viz.: 

The  frames  cannot  be  set  after  the  plastering  is  completed,  except  by  the  use 
of  temporary  frames  or  other  woodwork  to  furnish  a  guide  for  the  plasterer. 

After  the  temporary  woodwork  has  been  removed  and  the  permanent  frame 
set  the  joint  between  the  wood  and  plastering  must  be  filled  or  pointed,  but  the 
twisting  or  shrinking  of  the  wood  or  the  slamming  of  doors  break  the  putty  joint, 
and  it  is  then  even  more  unsightly  and  unsanitary  than  the  angle  between 
the  plastering  and  wooden  casings  which  it  is  endeavored  to  avoid. 

Steel  Frames  and  Casings. — Plastering  is  attended  with  the  use  of  so  much 
water  that  it  is  not  practicable  to  set  finished  door  frames  prior  to  the  plastering, 


78  HOSPITAL    ARCHITECTURE 

consequently  it  is  necessary  to  make  flush  frames  of  a  material  not  effected  by 
water.  Drawn  steel,  combined  frames  and  casings,  appear  to  be  the  first  suc- 
cessful casings  of  this  kind.  They  are  slightly  molded,  but  without  sharp  angles. 
The  edge  adjoining  the  plastering  is  raised  slightly,  so  that  if  the  joint  between 
steel  and  plaster  is  opened  by  the  slamming  of  doors  it  will  not  be  so  noticeable 
as  it  would  if  both  surfaces  were  wide  and  flush. 

The  cost  of  metal  doors  and  furniture  has  been  greatly  reduced  very  recently, 
and  it  is  possible  that  simple  metal  trims,  fitting  the  plaster  closely  and  coving 
away  from  its  surface,  will  soon  be  on  the  market.  If  this  is  realized,  the  objec- 
tion to  casings  will  fall  away,  for  there  will  be  no  internal  angles,  and  the  coved  and 
rounded  surfaces  can  be  cleaned  by  one  movement  of  the  moistened  cloth. 

The  hospital  architects  of  Germany  have  recognized  the  severe  appearance 
of  hospital  wards  on  account  of  the  omission  of  woodwork,  and  have  overcome 
this  successfully  by  designing  simple  painted  wall  treatments,  using  lines  and 
stencil  dots  or  stencil  ornaments  designed  in  good  taste,  outlining  the  door  and 
window  openings,  and  possibly  paneling  the  walls  by  the  application  of  painted 
lines.  Such  work,  in  the  hands  of  the  ordinary  house-painter,  would  be  worse  than 
the  severity  of  untrimmed  openings,  but  in  charge  of  a  competent  designer  can  be 
made  pleasing  and  can  be  obtained  at  a  low  cost.  It  must  not  be  forgotten,  how- 
ever, that  metal  door  and  window  frames  have  the  disadvantage  of  not  yielding 
to  repairs  in  the  event  of  a  door  or  window  warping,  as  will  sometimes  happen. 

PLASTERING  AND  WALL  FINISHES 

The  cement  wall  plasters  now  on  the  market  are  preferable  to  lime  and  sand, 
on  account  of  the  more  reliable  mixing  of  the  ingredients  and  on  account  of  being 
harder  after  setting.  For  walls  and  living-rooms  a  lime,  putty,  finishing  surface  is 
usually  hard  enough,  but  the  prepared  wall  surfaces,  such  as  the  U.  S.  Gypsum 
Co.'s  Universal  Finishing  Material,  is  somewhat  harder  and  denser.  The  same 
company's  gray  finishing  material,  if  thoroughly  troweled  with  a  steel  trowel, 
will  result  in  a  very  hard,  dense  surface  having  a  slight  polish.  Keene  cement, 
used  as  a  finishing  surface,  is  very  hard,  smooth,  and  dense.  The  No.  40  finishing 
material  or  Keene  cement  should  be  used  in  toilet-rooms,  bath-rooms,  operating- 
rooms,  dressing-rooms,  serving  pantries,  kitchens,  and  wherever  steam  is  used  in 
sterilizers  or  steam  tables.  In  cellar  and  basement  rooms  any  kind  of  plaster  mixed 
with  lime  should  be  avoided,  and  only  Portland  cement  and  sand  should  be  used. 
Plasterers  object  to  this,  for  it  is  difficult  to  apply  and  hard  to  work,  inasmuch  as 
it  is  not  as  fatty  as  lime  mortar,  and  the  average  journeyman  mechanic  will  insist 
on  adding  cement  to  lime  mortar,  but  the  result  will  not  be  efficient,  for  lime  is 
hygroscopic  and  will  dry  out  and  absorb  moisture  alternately,  showing  efflorescence 
on  the  surface  and  saponifying  the  oil  in  paints. 

INTERIOR  PAINTING 

The  modern  high-grade  enamel  paints,  made  of  Damar  varnish  and  pulverized 
quartz  or  spar,  are  best  suited  for  hospital  work,  and  should  unquestionably  be 
used  throughout  the  operating  departments,  dressing-rooms,  bath-rooms,  toilet- 
rooms,  excreta  closets,  and  wherever  steam  or  water  is  used  considerably,  and,  if 
the  means  will  permit,  such  material  should  be  used  throughout  the  hospital. 
Where  this  expense  cannot  be  met  the  walls  should  be  sized  with  oil  size,  and 
painted  with  not  less  than  three  coats  of  white  lead  and  linseed  oil.     Enamel 


DETAILS    OF   STRICTURE  79 

paint  and  oil  paints  can  be  tinted  to  any  desirable  shade,  and  it  is  quite  obvious 
iha i  the  lighter  shades  should  be  used,  but,  inasmuch  as  this  largely  is  a  matter 
of  individual  taste,  a  recommendation  by  the  author  will  serve  no  purpose. 

DETAILS  OF  EQUIPMENT  AND  MECHANICAL  ARRANGEMENT 

Screens 

Insect  screens  are  now  made  by  so  many  specialists  in  this  class  of  work  that 
i  hey  should  not  be  purchased  of  the  ordinary  mill  or  carpenter,  for  the  screen  makers 
have  machinery  for  producing  stronger  joints  than  the  ordinary  halving  or  tenon 
and  mortise,  also  for  special  rebates  and  interlocking  mouldings  to  secure  the  wire 
mesh  and  facilitate  its  replacing. 

There  are  also  several  manufacturers  of  metal-frame  screens.  In  the  first  of 
these  to  be  marketed  the  wire  mesh  could  not  be  replaced  except  at  the  factory, 
hut  this  is  not.  now  the  case  with  some  of  them. 

A  durable  wire  mesh  is  important;  bronze  wire  is  the  best;  tinned  wire,  also 
termed  "pearl  wire,"  and  galvanized  japanned  wire  are  named  in  the  order  of  their 
durability.  Inasmuch  as  the  life  of  metal  frames  is  probably  longer  than  that  of 
wooden  frames  only  bronze  wire  should  be  used  with  such  frames. 

Screens  should  be  the  full  size  of  the  window  opening,  so  that  windows  having 
double-hung  sash  may  be  opened  at  both  the  top  and  the  bottom. 

Sliding  screens  equipped  with  springs  to  hold  them  at  any  position,  either  at 
the  top  or  bottom  of  a  window,  can  be  obtained,  but  these  do  not  permit  the  open- 
ing of  both  the  top  and  bottom,  and  are  not  convenient  for  moving  to  different 
positions  by  the  nurses  when  the  windows  are  large. 

Miscellaneous 

Weather  Strips. — There  are  many  kinds  of  metal  weather  strips  on  the  market 
which  should  not  be  confounded  with  the  old-fashioned  wood  and  rubber  strips, 
which  soon  lost  their  efficiency  by  the  hardening  of  the  rubber.  The  cost  of  these 
is  not  high,  and  they  undoubtedly  make  for  comfort,  and  also  for  economy  in  the 
consumption  of  fuel,  and  reduce  the  amount  of  necessary  cleaning.  Such  strips 
do  not  cost  over  8  cents  per  lineal  foot,  so  that  the  stripping  on  a  window  of  average 
size  costs  about  $2.50. 

Hardware. — The  variety  of  hardware  now  manufactured  is  so  large  that  it  is 
not  necessary  to  describe  all.  The  points  of  greatest  importance  for  hospitals  are 
simplicity  and  durability.  A  ward  is  seldom  locked,  but  the  knob  latch  is  in  con- 
stant use.  This  should,  therefore,  be  well  made,  of  generous  size,  with  good  springs 
and  an  additional  "easy  spring."  Smooth  glass  or  porcelain  knobs  should  be  used, 
for  these  can  be  cleaned  easily  and  reveal  the  presence  of  dirt  and  dust. 

Doors  to  offices  and  supply  rooms  which  must  be  frequently  locked  and  un- 
locked should  have  .cylinder  locks;  entrance  doors,  sink-rooms,  pantries,  and 
doors  to  many  other  rooms  should  have  door  checks  and  springs  to  make  them 
work  noiselessly  and  automatically.  Practically  all  doors  should  have  door  checks 
to  prevent  their  slamming,  but,  inasmuch  as  the  cosl  of  the  only  satisfactory  checks 
is  about  S3.50  and  upward,  this  safeguard  against  noise  is  usually  omitted. 

Many  inexpensive  devices,  such  as  rubber  stops,  have  been  tried,  but  usually 
fail  on  account  of  lack  of  adjustment.  A  small  cylinder  secured  to  the  head  of  the 
door  and  a  plunger  on  the  door  itself  may  be  obtained  at  a  reasonable  price,  but 


80  HOSPITAL    ARCHITECTURE 

the  door  can  only  be  closed  slowly  when  one  of  these  is  attached  and  the  doors  are 
frequently  left  open  when  they  should  be  closed. 

Glass,  porcelain,  and  enameled  iron  push  and  kick  plates  are  easily  broken,  and, 
therefore,  plain  or  nickeled  brass  is  generally  used. 

Blanket  Warmer. — A  blanket  warmer,  such  as  illustrated  on  page  159,  for  an 
operating  department  will  be  sufficiently  insulated  if  the  floors,  partitions,  and 
covers  are  of  ordinary  hollow  clay  tile  or  gypsum  block  plastered  on  both  sides. 
The  doors  and  door  frames  should  be  of  iron  neatly  fitted  together,  and  the  floor 
should  have  a  guide  track  to  guide  the  carrier,  which  is  the  same  as  a  standard 
clothing  carrier  of  a  laundry  dryer.  The  dryer  recess  should  not  exceed  7  or  8  feet 
in  height,  and  should  have  a  flue  to  draw  off  moist  air.  Any  of  the  laundry-dryer 
makers  can  make  a  truck  for  carrying  the  blankets,  which  will  operate  satisfac- 
torily. 

Any  good  metal  door  and  frame,  about  2  feet  wide  and  7  feet  high,  as  obtain- 
able in  the  open  market  can  be  used.  The  heating  coil  can  be  the  usual  pipe  coil. 
The  blanket  warmer  can  be  built  by  local  mechanics  if  laundry-dryer  makers  are 
out  of  reach. 

The  coil  should  be  connected  to  the  line  of  steam  piping,  which  supplies  the  steam 
tables  and  sterilizers  with  steam  under  30  to  60  pounds  pressure,  because  the  heat- 
ing apparatus  of  the  building  may  not  be  in  operation  in  mild  weather. 

An  electric  light  on  the  ceiling  of  the  warmer,  with  an  indicating  switch  on  the 
wall  outside  of  the  door,  is  a  convenience. 


PERMANENT  INSTALLATION 

BOILER  AND  POWER  SUPPLY 

The  steam  supply  for  hospitals  includes  primarily  that  necessary  for  the 
heating  system,  for  sterilizing,  cooking  purposes,  water  heating,  for  laundry  equip- 
ment requirements,  and  for  the  elevators  and  other  motors,  such  as  the  fans. 
As  all  of  these  uses,  except  the  heating,  need  steam  of  high  temperature  (and  con- 
sequent high  pressure),  the  use  of  the  low-pressure  cast-iron  type  of  boilers,  as 
commonly  installed  for  heating  plants,  is  here  precluded,  unless  a  small  high- 
pressure  auxiliary  boiler,  such  as  a  vertical  boiler,  is  installed  solely  for  this 
purpose  with  no  connection  to  the  heating  apparatus.  This  requires  two  fires  in 
winter,  but  has  the  advantage  of  requiring  only  a  small  fire  in  summer. 

The  high-pressure  type  of  steel  boiler  in  some  of  its  usual  forms  is,  accordingly, 
almost  universally  installed.  In  small  institutions  the  fire-box  brick  enclosed  type 
is  often  used.  This  type  has  heat  passages  around  outside  of  the  shell  and  be- 
tween it  and  the  enclosing  brick  work,  thus  utilizing  the  outer  shell  as  added 
heating  surface.  Marine  type  boilers  are  also  used  in  somewhat  larger  sizes. 
They  are  self-contained,  installed  without  brick  work,  and  are  of  high  efficiency. 
Their  somewhat  higher  first  cost  is  an  offsetting  feature  which  may  decide  against 
their  use.  The  most  commonly  used  boilers,  however,  are  the  horizontal  cylin- 
dric  shell,  return  flue  boilers,  set  in  brick  work,  with  furnaces  and  grates  designed 
either  within  the  brick  work  of  the  setting  or  as  "Dutch  ovens"  in  front,  as  deter- 
mined by  size,  capacity,  coal  available,  space  limitations,  and  the  like. 

The  first  two  types  of  boiler  have  their  furnace  spaces  enclosed  within  the 
steel  water-containing  portions  of  the  boiler,  and  are  generally  found  objection- 
able on  account  of  their  smoke  production.     It  is  practically  impossible  with  many 


PERMANENT    INSTALLATION  81 

kinds  of  coal  to  so  fire  thorn  throughout  the  range  of  their  capacity  and  under  the 
usual  operative  conditions  that  smokeless  combustion  will  result. 

The  more  important  cities  are  recognizing  this,  and  many  restrict  their  use  to 
the  smaller  sizes  and  under  very  moderate  operative  requirements. 

The  return  flue  boilers  in  brick  settings  may,  on  the  other  hand,  have  their 
furnaces  properly  designed  to  suit  practically  any  of  the  commercial  grades  and 
kinds  of  fuel,  and  this  type  of  boiler  is  to  be  recommended  for  use  up  to  the  limit- 
ing size  and  capacity.  They  are  ordinarily  built  in  commercial  sizes  up  to  150 
II.  P.,  and  are  to  be  considered  when  the  plant  does  not  require  more  than.  say. 
three  of  this  size.  To  these  should  be  added  one  spare  boiler  beyond  the  maximum 
requirements  of  the  entire  hospital  service  load,  for  so  imperative  are  the  needs 
for  steam  in  a  hospital  that  a  reserve  boiler  should  always  be  available  in  case 
ot  accident,  and  principally  for  use  during  the  necessary  shut  clown  of  any  one  of 
the  other  units  for  cleaning. 

Where  the  power  or  steam  requirements  are  greater  than  above,  the  water 
tube  boiler  in  some  of  the  standard  high-grade  types  should  be  used.  These  are 
ordinarily  built  in  sizes  ranging  upward  from  175  to  200  H.  P.  Water  tube  boilers 
have  a  considerable  advantage  over  any  of  the  other  types  in  respect  to  safety,  cost 
of  maintenance,  and  length  of  life.  They  are  so  constructed  that  failure  or  deteri- 
oration of  one  part,  such  as  a  tube,  necessitates  only  the  renewal  of  that  part,  and 
leaks  or  other  failures  commonly  develop  in  these  boilers  only  as  minor  defects, 
readily  remedied. 

Automatic  stokers  of  a  type  suitable  to  the  coal  and  the  operating  conditions 
should  replace  hand-firing  in  the  case  of  larger  units  and  in  smaller  institutions 
whenever,  by  their  use,  labor  can  be  saved.  This  is  usually  the  case  when  more 
than  three  or  four  boilers  compose  the  installation. 

In  all  power  plants  coal-storage  space  must  be  considered,  and  in  the  larger 
ones  the  use  of  coal  bunkers  or  overhead  tanks  or  bins  are  advantageous.  espe- 
cially  where  automatic  stokers  are  employed. 

Coal  conveyors  and  elevators  and  apparatus  for  ash  handling  are  also  items 
to  be  provided  for  in  the  larger  boiler  plants.  The  boiler-room  location  should 
receive  early  consideration  and  a  liberal  space  be  provided.  Any  handicap  in  this 
department  is  a  continued  tax  upon  the  hospital  operating  cost. 

The  introduction  of  engines  and  electric  generating  units  is  a  problem  that 
hinges  upon  the  cost  of  electric  current  as  obtainable  from  outside  sources,  such  as 
city  or  public  electric-supply  companies. 

The  local  labor  costs  are  another  important  item,  and  in  case  of  hospitals,  say, 
with  ion  beds  or  larger,  the  solution  most  frequently  is  found  to  be  that  a  private 
power  plant  can  furnish  steam  and  electricity  for  light  and  power  more  economic- 
ally than  would  result  from  the  purchase  of  electric  current  from  outside  concerns. 

It  must  he  borne  in  mind  that  steam  must  lie  furnished  to  the  hospital  at  all 
times,  and  that  throughout  a  large  portion  of  the  year  the  steam  requirements  For 
heating  may  be  in  excess  of  that  for  power,  so  that  live  .-team  must  be  used  in  addi- 
tion to  the  exhausl  steam  from  engines.  Only  a  fraction  of  the  heat  in  the  steam 
entering  the  engine  cylinders  can  be  extracted  for  power  production  and  the 
remainder  i>  available  for  heating  purposes.  The  supply  of  the  exhaust  steam  i> 
often  adequate  for  heating  purposes,  except  during  extremely  cold  weather. 

It  should  be  home  in  mind  that  the  illuminating  service  and  heating  service  are 
not  simultaneous  (hiring  each  twenty-four  hours.  The  demand  for  heat  is  greatest 
during  the  morning  hours:  much  the  greater  part  of  electric  lighting  is  crowded 
into    the    late    afternoon    and    evening.     This   lack   of  coincidence  is  an  obstacle 


82  HOSPITAL    ARCHITECTURE 

to  the  economic  application  of  steam  to  heating  and  the  production  of  electric 
energy. 

The  added  cost,  then,  for  electric  current  throughout  the  heating  season  is  a 
very  small  item,  consisting  of  some  added  labor  and  some  investment  charges  to 
cover  the  generating  units;  thus  the  average  yearly  power,  light,  and  steam  bills 
are,  on  this  account,  lowered  considerably. 

In  the  case  of  all  hospitals,  however,  this  important  question  should  be  care- 
fully considered  well  in  advance  of  the  planning,  and,  like  all  of  the  engineering 
equipment  problems,  of  which  this  is  probably  the  most  important  in  a  financial 
sense,  it  should  be  answered  only  after  it  has  received  study  and  has  been  esti- 
mated in  detail  and  reported  on  by  some  experienced  engineering  authority. 

Frequently  the  question  arises,  will  it  not  be  expedient  to  buy  light  and  power 
from  a  commercial  company?  This  question  cannot  be  settled  alone  in  dollars 
and  cents.  It  must  be  borne  in  mind  that  the  hospital  needs  not  only  light  and 
power  for  the  motors,  but  exhaust  steam  for  heating,  boiler  heat  for  sterilizing  its 
considerable  quantities  of  water  necessary  in  all  modern  institutions  where  asepsis 
is  practised,  such  as  the  wash  and  dressing  waters  in  the  operating  department, 
and  the  high-pressure  steam  for  sterilizing  and  for  cooking  vegetables  and  the  like 
and  making  the  coffee  and  tea.  High-pressure  steam  can  be  carried  over  very  short 
distances,  if  it  is  to  be  efficient,  and  the  drop  in  efficiency  of  exhaust  steam  is  so 
great  in  the  pipes  that  the  losses  in  going  a  considerable  distance  render  the 
practice  prohibitive.  Pipes  well  covered  and  carried  through  tunnels  where  a  dry 
and  warm  temperature  can  be  maintained  will  deliver  efficient  steam  at  a  commer- 
cial price  300  or  400  feet,  but  beyond  this  the  losses  are  so  great  that  an  institution 
should  attack  such  a  proposal  very  reluctantly. 

Then,  again,  a  hospital  must  have  its  service  at  unusual  hours  that  cannot  be 
controlled,  and  a  commercial  plant  will  find  it  extremely  expensive  to  deliver  high- 
pressure  steam  even  a  short  distance  at  midnight,  or  even  to  be  always  ready  to  do 
so. 

Another  question  concerns  the  engineering  staff.  There  is  always  plumbing 
to  be  repaired  or  altered,  radiators  and  regulators  to  be  fixed,  and  work  for  an  elec- 
trician to  be  done.  The  hiring  of  this  work  in  small  jobs  and  in  frequent  visits 
of  those  mechanics  is  extremely  expensive,  while  one's  own  engineering  force  can 
do  it  all  as  a  part  of  the  day's  work.  There  are  also  innumerable  odd  jobs  that  good 
plumbers,  steamfitters,  and  electricians  can  do  not  strictly  within  those  trades  if 
a  small  shop  is  available,  such  as  mending  kitchen  utensils  and  machinery,  the  var- 
ious sterilizers,  and  a  great  part  of  the  operating  apparatus,  such  as  metal  beds, 
tables,  wheel  chairs,  and  so  on.  Many  of  these  men,  too,  are  most  ingenious  and 
initiative — they  can  make  splints,  mend  clocks,  construct  artificial  supports,  bed- 
rests of  special  pattern,  and  help  the  doctors  in  the  design  and  construction  of  spe- 
cial apparatus,  and  so  on  almost  ad  infinitum.  All  these  things  cost  too  much 
money  to  warrant  liberality  in  respect  to  them,  and  yet,  if  they  can  be  done  with 
a  force  working  for  wages  at  other  work,  there  will  be  a  constant  stimulus  for  the 
doctors  to  do  new  things  and  thus  progress. 

So  there  are  many  questions  to  be  answered  before  a  hospital  management  can 
decide  whether  or  not  to  build  and  operate  a  power  plant. 

General  Service  Steam  Piping. — Besides  the  steam  required  by  the  heating 
system  and  the  laundry  there  are  many  uses  for  steam  throughout  the  hospital, 
and  to  supply  these,  in  general,  a  steam  service  system  of  piping  should  be  brought 
from  the  boiler-room  and  extended  throughout  the  hospital  to  the  various  loca- 
tions where  this  service  is  required. 


PERMANENT   INSTALLATION  83 

Among  the  various  steam-using  utilities  will  be  kitchen  equipment,  including 
dish  washers,  steam  tables,  hot  plates,  coffee  urns,  steam  food  boilers,  jacketed 
cooking  kettles,  bakers'  proving  closets,  and  pastry  kettles. 

In  the  diet  kitchens,  steam  tables,  dish  heaters,  hot  plates,  the  autoclave,  steam 
tallies,  and  the  like  require  steam.  The  service  rooms  throughout  the  building 
will  need  steam  tables,  dish  sterilizers,  and  utility  sterilizers. 

Utility  rooms  will  have  similar  steam  requirements. 

Surgical  dressing-rooms  will  need  steam  for  instrument  sterilizers  and  water 
sterilizing  apparatus. 

The  blanket  warmers  should  also  receive  steam  from  these  service  lines. 

The  service  piping  system,  in  general,  should  be  designed  along  the  usual  lines 
of  high-pressure  steam  piping  service.  It  may  have  to  carry  a  working  pressure 
of  between  nO  and  80 pounds,  and  it  should  be  tested  to  at  least  120  pounds.  This 
necessitates  high-grade  heavy  valves  and  fittings  and  good  workmanship  through- 
out. 

In  general,  the  piping  system  should  extend  as  directly  as  possible  to  the 
various  locations  where  used,  and  should  be  exposed  and  accessible  for  inspection 
wherever  possible. 

The  lay-out  requirements  will  include  a  main  from  the  boiler-room,  this  branch- 
ing to  risers  throughout  the  building,  and  these,  in  turn,  having  small  branches 
running  directly  to  the  fixture  locations.  From  the  fixtures  return  branches  are 
carried  to  return  risers  and  these  assembled  in  a  return  main,  extending  back  to 
the  boiler-room,  where,  properly  trapped,  it  discharges  the  condensed  steam  into 
a  hot-water  collecting  tank,  or  to  a  boiler  feed  water  heater.  Valves  should  be 
provided  at  all  fixtures. 

As  the  above  description  would  indicate,  it  is  essential  that  all  of  the  various 
steam-using  items  of  equipment  be  selected  early  ami  their  location  within  the 
hospital  then  determined,  so  that  the  most  direct  and  economic  method  of  pip- 
ing and  equipment  can  be  determined  in  the  planning  of  the  building. 

The  detailed  designing  of  this  pipe  work  needs  expert  consideration,  and  it  will 
ordinarily  be  designed,  purchased,  and  installed  as  a  part  of  the  heating  power  and 
other  piping  work. 

HEATING 

The  comfort  of  patients,  and  the  carrying  on  of  the  various  activities  of  a  hos- 
pital, depend  so  largely,  throughout  a  considerable  portion  of  the  year,  upon  the 
proper  heating  of  the  rooms  that  the  hospital  heating  system  must  necessarily  be 
most  complete  and  effective. 

The  requirements  of  the  several  hospital  departments  are  so  specialized  that  a 
detailed  design  should  be  executed  by  experts  especially  experienced  in  hospital 
engineering. 

Among  the  requirements  for  a  satisfactory  hospital-heating  system  must  be 
considered  cleanliness  and  ease  of  maintaining  cleanliness,  noiselessness  at  all 
times,  prompt  and  ready  regulation,  and  this,  preferably,  through  a  considerable 
range  of  temperature',  freedom  from  leakage,  odors,  or  deleterious  effects  upon  the 
air  of  the  rooms,  with  simplicity  of  operation  and  substantial  design  throughout. 

The  special  air-supply  requirements  of  various  classes  of  rooms  project  the 
influence  of  ventilation  upon  the  heating  requirements,  and  tin-  design  of  the 
Ventilating  and  heating  equipments  should  go  hand  in  hand  and  should  receive 
equal  consideration. 


84  HOSPITAL    ARCHITECTURE 

As  to  the  various  types  of  heating  apparatus,  stoves  and  hot-air  furnaces  have 
proved  inadequate  and  unsuitable  to  high-grade  or  exacting  requirements,  and 
are  now  seldom  considered  in  hospitals  of  any  permanency  or  importance. 

Ho1>water  heating  systems  are  easily  managed  and  hold  a  uniform  heat  for 
some  considerable  length  of  time  without  attention,  and  they  are  accordingly  ser- 
viceable in  smaller  institutions. 

Where  the  matter  of  attendance  at  night  is  an  important  factor  the  slow  cool- 
ing of  the  system  is  an  advantage,  although  this  is  offset  largely  by  the  fact  that 
it  responds  with  equal  slowness  to  a  demand  for  more  heat.  This  system  is  at  a 
disadvantage,  in  that  it  requires  quite  a  considerable  increase  in  the  size  of  the 
piping  and  all  of  the  radiators  over  that  required  by  steam  heat,  hence  it  is  also 
more  expensive  to  install. 

Steam  heat  is  more  extensively  used  in  hospital  practice.  Of  the  several 
steam-heating  systems  the  simplest  is  the  plain  or  gravity  system.  The  single- 
pipe  method  of  piping  is,  in  general,  the  least  expensive,  and  may  adwsedly  be 
adopted  in  smaller  institutions,  where  the  distances  of  pipe  runs  are  short,  and 
accordingly  permit  satisfactory  uniformity  of  operation  throughout  the  building. 

With  this  system  there  is  the  objectionable  feature  of  air  valves  on  radiators, 
which  allow  the  escape  to  the  rooms  of  objectionable  air  from  the  radiators  when- 
ever steam  is  turned  on. 

An  auxiliary  air  discharge  line  system,  connecting  all  the  air  valves  to  an  outlet 
in  the  boiler-room,  though  an  added  expense,  is  desirable  in  any  installation  of  this 
type. 

Larger  buildings  require  a  more  effective  piping  system  and  added  devices  to 
insure  proper  uniformity  of  heating  throughout  their  extent.  Steam-heating 
systems  in  these  cases  should  have  the  two-pipe  system  for  supplying  steam  and 
returning  the  condensed  steam  from  radiators  to  the  boilers. 

The  so-called  vacuum  systems  of  steam  heating  include  specially  designed 
vacuum  valves  or  traps  between  the  radiators  and  the  return  piping  and  a  vacuum 
pump  in  the  machinery  room  operated  to  draw  a  vacuum  in  the  return  piping 
system,  thus  inducing  prompt  removal  of  air  and  more  rapid  and  complete  fill- 
ing of  the  radiators  with  steam.  In  consequence,  the  operation  of  the  heating 
system  at  a  lower  steam  pressure  is  possible  with  these  systems. 

Vacuum  systems  are  of  special  value  where  the  heating  system  takes  steam  from 
the  power  plant,  utilizing  engine  exhaust.  As  the  steam  can  be  delivered  to  the 
heating  system  at  practically  atmospheric  pressure  a  resultant  saving  in  the 
capacity  and  economy  of  the  engines  thus  obtains. 

A  recent  development  of  temperature-control  valves  for  radiators  deserves 
especial  attention  in  connection  with  hospital  installations.  These  are  designated 
by  the  various  makers  by  different  trade  names,  such  as  vapor  systems,  modula- 
ting systems,  vacuo-vapor,  thermograde  systems,  and  the  like. 

They  are  substantially  similar  in  principle,  and  furnish  essentially  some  type 
of  hand-control  lever  valve  on  the  radiators  with  indicating  disks  marked  in  frac- 
tional parts  and  designed  for  setting  at  f ,  §,  f,  or  the  full  capacity  of  the  radiator. 
These  systems  need  a  proper  and  ample  piping  system,  efficient  regulating  valves 
on  the  main  steam-supply,  so  operating  that  they  assure  a  positively  uniform  steam- 
pressure  at  all  radiators  and  with  a  return  piping  system  carrying  back  the  con- 
densed steam  and  any  entrained  air.  These  systems  operate  most  effectively  to 
permit  the  use,  at  will,  of  either  the  entire  radiator  or  approximately  such  frac- 
tional parts  of  it  as  is  desired  by  simply  turning  the  valve  to  the  desired  indicated 
position. 


PERMANENT    INSTALLATION  85 

The  systems  give  by  far  the  best  control  of  radiators  that  has  yet  appeared 
and  their  use  will  result  in  a  very  considerable  saving  of  coal-supply.  Manu- 
facturers claim  and  will  guarantee  a  saving  of  between  15  and  25  per  cent,  of  the 
season's  coal  bill.  This  is  largely  due  to  the  fact  that,  with  the  usual  systems, 
the  temperature  control  in  rooms  almost  universally  is  attempted  by  closing  and 
opening  windows,  with  the  resultant  loss  of  heat  from  the  building. 

These  systems  require  radiators  of  the  hot-water  type,  but  intermediate  in 
size  between  those  required  for  steam  heating  and  for  hot  water.  The  cost  of  these 
installations  is,  in  the  larger  buildings,  somewhat  less  than  that  of  hot-water  heat- 
ing systems. 

Large  institutions,  especially  those  including  a  number  of  buildings  separated 
over  some  considerable  area,  will  ordinarily  have  their  own  power  and  electric 
generating  plants.  These  may  well  consider  the  installation  of  a  system  of  forced 
circulation  of  hot  water,  which,  while  equipped  in  the  various  buildings  and  rooms, 
practically  the  same  as  in  the  ordinary  hot-water  heating  system,  has  a  circula- 
ting pump  connected  to  the  main  supply  pipe  in  the  power  plant  or  supply  point, 
so  that  the  water  is  circulated  rapidly,  positively,  and  uniformly  throughout  the 
whole  institution. 

One  advantage  of  a  forced  circulation  of  hot  water  is  that  the  water  can  be  cir- 
culated at  a  positive  uniform  speed  under  all  conditions,  while  the  temperature 
of  the  water  can  be  varied  to  suit  the  varying  demands  for  heat  in  accord  with 
the  outdoor  temperature  changes.  The  temperature  of  the  whole  institution 
is  then  readily  regulated  in  the  engine-room  as  the  variation  of  the  temperature 
of  the  hot-water  supply  can  be  controlled  by  a  single  steam  valve.  The  control 
of  temperature  in  the  rooms  is  readily  regulated  by  adjusting  the  individual  radi- 
ator valves. 

Inasmuch  as  the  varying  hot-water  temperature  demands  are  best  made  by 
varying  the  steam-supply  temperatures,  the  main  advantage  of  this  type  of  heat- 
ing systems  is  that  it  permits  the  power-plant  engines  to  be  run  much  more  eco- 
nomically as  condensing  engines,  exhausting  their  steam  under  a  varying  vacuum 
(and  thus  at  a  corresponding  variation  of  temperature),  which  will  follow  the 
heating  requirements  very  closely.  This  utilization  of  the  low-temperature  steam 
will  permit,  through  the  use  of  condensing  engines,  a  probable  saving  of  coal 
costs  over  non-condensing  engines  of  between  15  and  25  per  cent,  throughout  the 
beating  season. 

The  cost  of  this  system  should  not  be  much  in  excess  of  that  of  the  usual  hot- 
water  heating  system.  The  added  cost,  however,  is  more  than  offset  by  the  gain 
in  economy  of  operation. 

Referring  to  details  of  construction,  the  item  of  radiators  in  hospitals  is  im- 
portant, regardless  of  the  system  selected.  Those  of  the  simplest  and  plainest 
design  should  be  the  only  ones  chosen,  as  the  so-called  ornamentation  serves  to 
collect  dirt  and  increases  the  cost  of  keeping  them  clean,  or  results  in  their  always 
being  foul.     The  type  of  ornamentation  is,  moreover,  frequently  obtrusively  ugly. 

The  proper  location  of  radiators  should  always  receive  study,  ami  the  services 
of  an  experienced  designer  is  here  required. 

Extra  high  legs  on  radiators  are  most  advantageous,  as  they  permit  the  more 
rapid  cleaning  of  the  floor.  Better  still  is  the  use  of  legless  radiators,  supported 
free  from  the  floor  by  bracketed  attachments  to  the  side  walls.  These  are  largely 
contemplated  now  in  the  better  class  of  hospital  designs. 

The  use  of  radiators,  having  especially  large  and  free  -paces  between  tin  cast- 
iron  sections,  is  most  advantageous  for  facilitating  ready  cleaning,  and.  although 


8b  HOSPITAL    ARCHITECTURE 

such  radiators  occupy  more  space  and  are  slightly  higher  in  cost,  their  use  in 
hospitals  is  recommended.  In  operating-  and  similar  rooms  they  should  always  be 
insisted  upon. 

The  desire  to  keep  operating-rooms  as  free  as  possible  from  all  apparatus, 
fittings,  and  other  items  other  than  surgical  apparatus  has  resulted  in  a  number 
of  special  methods  of  heating  such  rooms.  Notably  among  these  have  been 
some  operating-rooms  recently  constructed,  with  their  interior  walls  made  up 
almost  entirely  of  opalescent  glass,  and  between  these  inner  walls  and  the  parti- 
tion walls  steam  coils  and  radiators  have  been  installed,  so  that  the  entire  wall 
surface  of  the  rooms  is  so  heated  as  to  keep  the  room  at  the  required  tempera- 
ture. This  system  needs  especial  attention  in  design  to  preclude  the  necessity 
for  attention  or  repairs  and  some  extra  building  space  has  to  be  provided  for  it; 
but  the  operation  is  so  entirely  satisfactory  that  the  added  expense  is  more  than 
justified. 

In  the  halls,  corridors,  lecture  rooms,  and  general  public  sections  of  hospital 
buildings,  where  uniformity  of  temperature  is  more  desirable,  the  added  expense  of 
a  system  of  thermostatic  control  for  radiators  is  usually  justifiable  in  connection 
with  the  heating  system.  These  consist,  in  general,  of  a  system  of  thermostats 
mounted  on  the  room  walls,  and  so  connected  electrically  or  by  an  air-pressure 
piping  system  to  specially  designed  radiator  valves  that  a  change  of  two  or  three 
degrees  in  the  temperature  of  the  room  will  cause  them  to  automatically  regulate 
the  radiator  valves  to  hold  the  temperature  constant. 

The  details  of  heating  system,  piping,  valves,  and  equipment,  including  the 
method  of  running  piping  and  the  like,  should,  of  course,  be  left  in  the  hands  of 
experienced  engineers,  with  whom  the  architects  will  co-operate  to  provide  space 
and  facilities.  It  should  be  stated,  however,  that  in  no  other  service  is  excellence 
of  design  or  high  quality  of  equipment  so  essential  as  in  hospital  work,  as  the 
operating  requirements  are  most  exacting  and  low  cost  for  attention  and  repairs 
is  most  desirable. 

While  it  is,  in  general,  advisable  throughout  the  hospital  construction  to  keep 
all  rooms  as  free  as  possible  from  fixtures,  apparatus,  and  fittings  not  actually 
necessary,  the  question  of  whether  the  heating-system  pipes,  such  as  risers  and 
returns,  should  be  left  exposed  or  hidden  in  the  walls  is  one  of  the  problems  of 
hospital  architecture.  Concealed  piping  is  difficult  to  reach,  and  occasionally  a 
leak  will  appear  that  may  mean  a  break  anywhere  within  several  floors,  and  a 
great  amount  of  wall  may  have  to  be  torn  out.  But  modern  plumbing,  with  cast 
pipe  and  threaded  joints,  has  made  such  forward  strides  that  such  leaks  are  very 
rare,  especially  in  concrete  construction. 

On  the  other  hand  exposed  piping  is  hideous  to  look  at,  intolerable  in  the 
rooms  and  wards  of  a  hospital,  impossible  to  keep  clean,  and  necessitates  loose 
connections  at  the  ceiling  openings,  which  may  easily  be  the  avenues  by  which 
infections  may  be  spread  upward  or  downward.  Assuming  good  construction  in 
both  cases,  the  cost  and  upkeep  will  be  pretty  nearly  the  same. 

PIPE  COVERING 

Discretion  in  selecting  piping  covering  or  insulation  for  the  various  piping 
systems  will  result  in  considerable  saving  of  cost  of  installation,  combined  with 
the  most  economical  operative  and  maintenance  expenditures.  The  highest  grade 
of  insulation  for  high-pressure  steam  and  refrigerating  piping  is  essential.  Cold- 
water  pipes  need  insulation  only  to  prevent  condensation  of  moisture  upon  them. 


PERMANENT    INSTALLATION  87 

Hot-water  piping  should  have  a  good  grade  of  insulation.  Steam-heating  sys- 
tem piping,  where  passing  through  heated  rooms,  needs,  in  general,  only  enough 
insulation  to  protect  the  room  occupants  in  case  of  accidental  contact,  but  if  these 
arc  embedded  in  outer  walls  they  should  have  high-grade  insulation.  As  with 
other  details  of  the  engineering  equipment,  trained  technical  advice  is  advisable 
in  making  an  economic  selection  of  insulation. 

LIGHTING 

Beside  the  usual  problems  of  efficient  interior  building  lighting  called  for  by 
offices,  assembly  rooms,  corridors,  halls,  and  service  rooms,  a  hospital  presents 
many  problems  peculiar  to  its  own  class  of  service. 

Most  modern  hospitals  are  so  located  that  electric  current  is  available  either 
from  outside  sources  or  from  local  power  plants,  and,  on  account  of  its  decided 
advantages  over  other  systems,  electricity  has  practically  superseded  all  other 
forms  of  illumination  in  hospitals.  Throughout  the  service  rooms  and  those  given 
over  to  the  use  of  the  public,  the  illumination  is  governed  to  a  certain  extent  by 
the  architectural  treatment,  but  more  usually  by  the  location  of  furniture  and 
fixtures. 

The  tendency  in  modern  practice  is  to  provide  the  best  possible  light  dis- 
tribution without  overintensity.  Standard  fixtures  are  available  in  a  variety  of 
types,  which  allows  of  ready  selection  to  suit  any  condition  or  requirement. 

Patients'  rooms,  and  wards  in  general,  require  a  soft,  subdued  light,  and  the 
so-called  indirect  systems  are  gaining  in  favor.  These  systems  use  inverted  light- 
ing fixtures,  which  throw  the  light  directly  to  the  ceiling,  whence  by  reflection  it  is 
diffused  throughout  the  room.  Either  with  this  system  in  use,  or  with  the  use  of 
ordinary  ceiling  fixtures,  side-wall  bracket  lights  are  essential  for  use  when  doctors 
or  nurses  are  working  about  the  patients. 

Wall  plug  outlets  for  attachment  of  cords,  with  portable  lamps  for  doctors' 
use,  are  of  great  assistance,  and  are  commonly  included  in  the  equipment.  These 
outlets  are  also  available  for  use  with  the  many  serviceable  electric  specialties 
now  on  the  market.  Foremost  among  these  are  electric-warming  pads,  which 
seek  to  displace  the  usual  hot-water  bottles. 

There  still  exists  unfilled  a  demand  for  a  practical  adjustable  wall-bracket 
light  shade  which  will  permit,  at  will,  a  variation  of  intensity  or  direction  of  light ; 
in  consequence,  unsightly  temporary  shades,  constructed  impromptu  from  news- 
papers, magazine  backs,  and  the  like  are  seen  frequently  in  use. 

A  desirable  fixture  arrangement,  especially  in  rooms  used  by  convalescent 
patients,  is  a  pendant  switch  on  a  cord,  arranged  to  be  available  at  the  patient's 
hand,  and  by  which  the  bracket  light  above  the  bed  can  be  turned  on  or  off  at  will. 
This  makes  a  very  complete  and  convenient  fixture  when  a  wall  switch  for  nurses' 
use  is  included  at  the  bracket. 

The  lighting  of  operating-rooms  is,  no  doubt,  the  most  difficult  of  hospital- 
lighting  problems,  and  many  methods  are  in  use  and  many  more  have  been  ex- 
perimented with.  Obviously  the  light  should  correspond  in  direction,  source,  in- 
tensity, and  color  as  nearly  a-  possible  to  daylight  illumination  entering  through 
the  large  north  windows.  Figure  25  shows  a  combination  of  daylight  and  night 
illumination. 

Modern  incandescent  lamp  filaments  are  more  anil  more  nearly  approaching 
daylight  color.  The  location  of  light  source  has  many  practical  limitations. 
Fixtures  extending  into  the  room  continually  gather  dust,  and,  when  lighted  and 


88  HOSPITAL    ARCHITECTURE 

thus  heated,  they  induce  air  currents  which  tend  to  circulate  the  dust  around  the 
room.  Groups  of  lights  in  fixtures  hung  from  the  ceiling  are,  on  these  accounts, 
more  or  less  of  a  menace  and  are  difficult  to  keep  clean.  The  cleaning  may  be 
facilitated  by  having  the  fixtures  made  adjustable  and  counterbalanced.  Port- 
able banks  of  lights  fitted  upon  stands  with  heavy  iron  bases  have  been  much  used, 
but  lamp  cords  are  then  under  foot  and  the  fixtures  usually  in  the  way. 

Groups  of  lights  under  a  large  reflector  on  swinging  brackets  (Fig.  28)  are  also 
in  use.  These  do  away  with  some  of  the  objections  to  floor-stand  fixtures,  but  are 
open  to  the  same  objections  as  to  dust  collection  as  are  ceiling  fixtures.  It  is 
rather  difficult  to  so  locate  this  type  of  fixture  as  to  avoid  objectionable  shadows. 
Large  groups  of  lamps  placed  close  to  the  operating  table  are  also  objectionable, 
on  account  of  the  heat  which  they  generate. 


Elevation  Hi  -Section- 

Fig.  25. — Combined  operating-room  window  and  skylight. 


Some  operating-rooms,  especially  abroad,  have  had  installed  systems  of  strong 
arc  lights  equipped  with  lenses  and  reflectors,  and  placed  outside  of  the  operating- 
room  walls  at  such  locations  as  to  direct  and  concentrate  their  rays  about  the  opera- 
ting table.  These  are  rather  expensive  systems,  but  if  the  lamps  are  well  placed 
are  effectual,  though  surgeons  using  them  complain  of  the  heat  they  generate  and 
also  of  the  intensity;  at  the  same  time  the  limited  area  of  the  light  focus. 

A  very  effective  method  of  illumination  in  operating-rooms,  which  has  been 
recently  installed  in  some  hospitals,  makes  fixtures  or  lighting  devices  within 
the  room  unnecessary.  (See  Figs.  26,  27.)  It  is  made  up,  in  general,  as  a  con- 
tinuous box  or  trough  installed  in  the  side  walls  and  ceiling  of  the  room  and  en- 
circling the  north  light  window  frame.  This  trough  is  provided  with  a  glass  front 
set  tightly  in  a  frame  work  flush  with  the  plaster.  It  is  found  that  an  ample 
number  of  lights  can  be  installed  in  this  fixture  to  give  proper  intensity  of  illu- 
mination, and  the  glass  being  made  prismatic  or  ribbed  good  diffusion  results. 


PERMANENT    INSTALLATION 


89 


A  recently  developed  form  of  incandescent  light,  shaped  as  a  straight  tube  about 
a  foot  long  and  supplied  with  a  straight  filament,  can  be  so  placed  in  these  troughs 
as  to  make  the  light  source  a  continuous  line  in  the  troughs  and  thus  give  perfect 
uniformity  of  illumination. 

The  above  type  of  lighting  fixtures,  forming  as  it  does  a  part  of  the  wall  surface, 
is  tight  and  free  from  dust  circulation  and  as  readily  kept  clean  as  are  the  walls 
themselves. 

The  Moore  light,  a  type  of  illumination  now  being  developed,  promises  much  in 
the  way  of  a  uniformly  diffused  light  source  of  good  quality.  This  light  is  made  up 
within  the  rooms  to  lie  illuminated  as  a  continuous  glass  tube,  and  consequently 
may  be  located  wherever  desired.  The  light  source  is  a  luminous  vapor  existing 
throughout  the  extent  of  the  tube,  this  being  controlled  electrically  and  mechanic- 


I  NT  C&IOE.  VI  EW 

Fig.  26. — Interior  view,  operating-room  windows  showing  linolitc-  lighting  around  windows 


ally  by  the  very  ingeniously  contrived  automatic  devices  forming  a  part  of  the 
lamp.  This  lamp  in  the  above  form  has  not  as  yet  been  developed  commercially 
to  any  extent,  although  the  makers  are  now  furnishing  a  small  portable  lamp 
unit,  consisting  of  parallel  illuminating  tubes  framed  with  a  suitable  reflector  to 
form  a  lighting  surface  about  2  feet  square.  Some  of  these  have  recently  been  set 
Up  in  hospital  operating-rooms,  and  especially  on  account  of  the  fact  that  the 
quality  of  the  light  furnished  approximates  sunlight  very  closely  considerable 
success  is  claimed  for  them. 

Lighting  Fixtures. — Lighting  fixtures  should  be  selected  for  simplicity.  The 
tubing  anil  other  metal  of  wall  brackets  should  lie  heavy  to  withstand  usage. 

If  the  "indirect"  types  of  fixtures  are  chosen,  particular  attention  should  be 
given  to  their  reflecting  surfaces,  for  some  of  them  deteriorate  so  rapidly  that  the 
illumination  suffers.  Such  fixtures  require  light-colored  ceilings,  preferably  enamel 
paint,  in  order  to  reflect  the  light  as  much  as  possible. 


90 


HOSPITAL    ARCHITECTURE 


In  any  case  much  light  is  absorbed  by  the  reflectors  and  the  ceilings,  and, 
unless  the  most  efficient  lamps  (with  Tungsten  filaments)  are  used,  an  excessive 
amount  of  current  will  be  consumed  to  give  the  required  illumination  throughout 
the  rooms. 

There  are  two  forms  of  light  regulation  for  private  wards  and  rooms  that  have 
recently  become  popular.     One  is  called  the  "high  low"  and  the  other  the  "dim- 


Fig.  27. — Section  of  operating-room  windows  showing  linolite  lighting  around  windows. 


mer."  In  the  former  there  is  resistance  in  the  lamp  filament,  and  in  the  latter 
the  resistance  is  in  the  socket.  In  both  there  is  a  tiny  chain  attachment  that  when 
manipulated  turns  the  light  up  or  down,  just  as  an  oil  lamp  may  be  turned  up  or 
down.     The  difference  between  the  two  forms  is  one  of  cost.     The  "dimmer" 


PERMANENT    INSTALLATION 


91 


socket  costs  about  75  cents,  Imt  is  as  permanent  as  any  other  socket.     The  "high 
low"  lamp  costs  25  cents,  but  the  lamp  is  short-lived,  perhaps  one-quarter  the  life 


28. — An  admirable  lighting  for  operating-room. 


of  an  ordinary  lamp,  and  must  then  be  renewed.     One  or  other  of  these  lamps  is 
almost  necessary  in  the  hospital  sick-room. 

SIGNALLING  SYSTEMS 

Beside  the  usual  public  and  private  telephone  systems  with  which  modern 
hospitals  are  equipped,  the  special  needs  of  hospital  service  call  for  reliable  signal- 
ling systems  for  a  number  of  purposes.  An  electric  system  of  signals  for  calling 
nurses  to  the  patient's  bedside  is  now  considered  essential.  The  simplest  and  gen- 
erally the  least  expensive  type  of  these  is  the  annunciator  system.  This  is  quite 
similar  to  those  usually  installed  in  hotels.  An  annunciator  located  at  the  curses' 
desk  or  station  in  the  corridor  has  drops  or  signal  disks,  numbered  or  lettered  to 
designate  the  various  rooms  or  patients'  bed  locations  in  wards.  A  pear-shaped 
bush  button  attached  to  a  flexible  insulated  wire  or  cord  is  furnished  at  each  bed 
anil  wired  electrically  from  the  bedside  location  to  the  annunciator,  where  the 
patient's  call  is  announced  whenever  the  button  is  pushed. 

To  attract  the  attention  of  nurses  from  a  distance  an  electric  bell  or  buzzer  is 
located  at  the  annunciator,  or  an  electric  light  is  installed  and  so  wired  as  to  be 
lighted  whenever  a  call  is  shown  on  the  annunciator.  Resetting  the  annunciator 
when  answering  the  call  extinguishes  the  light  until  another  call  is  sent  in. 

A  marked  improvement  is  an  extension  of  this  system,  accomplished  by  adding 
electric  resetting  circuits,  so  wired  that  to  reset  or  cancel  the  call  from  the  annun- 


92  HOSPITAL    ARCHITECTURE 

ciator  the  nurse  must  go  to  the  room  and  push  a  button  located  at  the  bedside 
outlet  from  which  the  call  originated.  This  guarantees  that  in  every  case  the 
signal  is  responded  to  in  person,  and  that  if  a  signal  is  canceled  from  an  annunciator 
this  has  been  done  by  some  one  at  the  patient's  bedside.  The  importance  of  this 
feature  of  the  service  is  at  once  apparent.  The  only  trouble  is  that  in  case  the 
nurse  fails  to  answer  promptly  the  patient  may  undertake  to  call  again  by  another 
push  on  the  button,  and  so  put  out  the  annunciator  light.  To  obviate  this  the  shut- 
off  light  may  be  placed  near  the  door,  inside  the  patient's  room,  when  the  nurse 
can  use  it  immediately  on  entering  and  so  cancel  the  call,  but  where  the  patient 
cannot  reach  it. 

A  supervisory  annunciator  can  be  readily  added  to  this  system.  This  is  a 
large  annunciator,  located  at  the  superintendent's  or  other  official's  desk,  and 
having  signal  drops  duplicating  those  on  the  entire  equipment  of  the  signal  annun- 
ciators throughout  the  hospital  and  working  in  unison  with  them.  This  places 
before  the  official  continuously  a  visual  record  of  unanswered  calls,  and  should  tend 
to  very  considerably  increase  the  efficiency  of  this  most  important  item  of  the 
nursing  service. 

More  extensive  elaborations  of  the  above  signalling  systems  have  been  devel- 
oped. In  place  of  the  usual  type  of  annunciators  these  have  the  signal  cases  con- 
taining electric  lamps  to  indicate  the  calls  instead  of  numbered  drops  or  disks. 
These  lights  are  visible  and  readily  discernible  at  greater  distances  and  tend  toward 
bettering  the  service. 

These  signal  cases  may  have  a  large  or  pilot  light  located  above  them  or  at  any 
required  location,  and  so  wired  as  to  be  lighted  and  give  indications  that  a  signal 
is  recorded  or  a  call  unanswered  at  the  station.  Lights  placed  above  the  doors  of 
the  patients'  rooms  or  wards  may  be  installed  to  serve  as  additional  signals  to  safe- 
guard each  call  and  facilitate  prompt  attention.  Electric  resetting  devices  in  the 
various  rooms  are  similarly  used  with  the  various  light  signal  systems. 

The  latest  refinement  in  the  matter  of  record  keeping  has  recently  been  brought 
out  in  the  form  of  a  supervisory  chart-drawing  electric  recorder.  This  has  a  con- 
tinuously moving  clock-driven  record  sheet  upon  which  pens,  operating  in  unison 
with  their  corresponding  patient's  call  signal  lights,  leave  a  line  measurable  as 
minutes  on  the  chart,  and  which  indicates  the  exact  time  of  calling  and  of  answer- 
ing every  patient's  call  throughout  the  day.  These  charts  can  be  taken  each  day 
from  the  recorder,  and  the  bound  sheets  form  a  written  record  always  available. 

With  increasing  elaboration  of  the  signal  systems  there  increases,  in  general, 
the  complication  of  construction.  Care,  judgment,  and  experience  are  essential 
in  selecting  the  type  best  adapted  to  the  hospital  service  requirements.  The  grade 
of  construction  and  material  should  be  of  the  best,  thus  insuring  length  of  life  and 
certainty  of  operation  of  the  system. 

Important  to  be  kept  in  mind  as  essential  is  the  selection  of  the  most  reliable 
and  constant  source  of  electric  current,  whether  from  dry,  wet,  or  storage  batteries, 
or  by  transformers  or  from  the  lighting  current.  In  general,  it  is  better  if  all  the 
bell  signalling  and  other  service  current  can  be  supplied  from  one  central  source 
of  energy.  Current  from  the  hospital  lighting  system,  if  perfectly  adaptable,  is 
preferable  to  storage  batteries,  and  these,  in  turn,  in  cost  of  upkeep  and  uniformity 
of  electric  output  are  more  serviceable  than  wet  or  dry  batteries.  Care  must  be 
taken  that  none  of  the  lighting  current  can  reach  the  patients'  push  cord,  and,  to 
avoid  this  possibility,  it  may  be  preferable  to  use  storage  cells  that  can  be  charged 
from  the  lighting  circuit  whenever  necessary.  In  small  installations  the  simplicity 
of  dry  batteries  as  a  current  source  renders  this  type  acceptable. 


PERMANENT    INSTALLATION  93 

Among  other  details  of  the  nurses'  signal  service  bedside  wall  outlets  should 
receive  attention.  These  should  he  located  so  as  not  to  be  disturbed  or  injured 
when  moving  the  beds.  The  cords  at  the  lied  should  he  heavy  and  of  best  quality. 
The  pear  push  button  should  be  smooth,  readily  cleaned,  and  as  aseptic  as  pos- 
sible. 

Beside  the  doctors'  call  system,  to  be  referred  to  later,  other  miscellaneous 
signalling  service  systems  about  the  hospital  include  elevator  call-bells,  with  pushes 
mi  each  floor  and  annunciators  in  the  cars;  dumb-waiter  calls,  with  pushes  at  each 
floor  connected  to  an  annunciator  at  the  service  floor,  and  with  the  gang  of  answer- 
ing push  buttons  on  the  service  floor  connected  each  with  a  corresponding  answer- 
ing hell  at  I  lie  various  floors. 

A  speaking  tube  at  the  dumb-waiter  location  is  an  added  facility  now  usually 
considered  essential. 

DOCTORS'  CALL  SYSTEM 

For  the  prompt  and  silent  signalling  of  house  physicians,  staff  physicians,  and 
interns  a  very  effective  system  is  that  of  having  banks  of  incandescent  lights 
installed  in  prominent  locations  on  the  various  floors  of  the  hospital,  as  in  corri- 
dors. These  lights  may  be  set  either  exposed  in  a  vertical  row  on  the  side  wall  and 
be  distinctively  colored,  or  they  may  be  boxed  in  by  an  appropriate  fixture  or  case 
with  ground  glass  sides,  having  numbers  or  letters  corresponding  to  each  lamp  to 
designate  the  various  persons  to  be  called. 

These  lights  are  electrically  connected  with  a  set  of  push  buttons  grouped  at  a 
central  point  (usually  at  the  telephone  switchboard  operator's  desk),  and  in  such 
a  manner  that,  in  the  event  a  doctor  is  wanted,  the  pushing  of  his  respective  button 
puts  in  service  his  light  signal  in  all  of  the  corridors  or  signal  locations  throughout 
the  hospital.  Me  can  at  once  get  in  communication  with  the  telephone  operator 
from  the  nearest  telephone.  • 

These  systems  are  usually  operated  directly  from  the  electric  current  of  the 
house-lighting  system,  and  are  usually  installed  as  a  part  of  it  and  of  a  similar 
standard  of  construction. 

SEWERAGE  AND  PLUMBING 

Drain  pipes,  inside  or  under  the  basement  floor,  should  be  of  iron  to  the  connec- 
tions witli  ordinary  drains  outside  of  the  walls.  The  best  material  for  outside 
drains  is  salt-glazed  clay  pipe.  In  localities  where  iron  piping  or  labor  to  lay  such 
is  too  expensive  clay  tile,  surrounded  in  good  cement  concrete,  is  a  good  substitute 
for  iron  drains.  For  these  a  bed  of  concrete  about  3  inches  in  thickness  should  be 
laid  first,  projecting  about  3  inches  each  side  of  the  drain,  and  the  space  each  side 
filled  with  concrete  to  prevent  irregular  settlement  and  opening  of  joints. 

Drains  for  chemical  laboratories  should  lie  salt-glazed  pipe. 

The  vertical,  soil,  and  waste  pipes  should  also  be  of  iron.  For  these  and  the 
iron  drains  either  extra  heavy  asphalted  inside  and  outside  cast-iron  pipe  and 
Bttings  with  caulked  and  leaded  joints  must  be  used,  or  asphalted  steel  pipes,  such 
.■I-  steam  pipes  with  screw  joints  and  special  fittings  threaded  and  recessed,  so  that 

the  passage  through  t  he  lit  tings  will  be  smooth  and  have  the  same  diameter  as  the 

pipes. 

Where  the  city  drains  are  too  small  to  carry  off  the  waste  and  roof  water,  or  so 
located  thai  water  will  back  out  of  the  fixtures  on  the  lowest  floor  during  storms, 
the  drainage  system  should  be  divided  into  two  parts,  one  part  conducting  the  \\ :  i  —  1 1  ■ 
from  the  upper  floors  and  roof  to  the  city  drains  without  an  opening  closer  than  ID 


94  HOSPITAL    ARCHITECTURE 

to  12  feet  above  the  city  drain,  and  the  other  part  leading  all  waste  into  a  sump 
equipped  with  an  automatic  ejector.  These  are  operated  by  electricity,  com- 
pressed air,  or  steam,  and,  if  the  waste  consists  only  of  water,  a  duplex  equip- 
ment may  be  obtained  for  $500  or  $600;  but  if  the  waste  is  also  from  closets,  the 
lowest  cost  for  a  duplex  equipment  is  about  $1200,  and  from  these  prices  upward, 
depending  upon  the  amount  of  waste.  The  best  known  of  these  ejectors  are  the 
Priestman,  Shone,  and  Yeomans,  all  of  which  are  good. 

The  drains  from  the  upper  stories  should  be  suspended  from  the  basement 
ceiling,  unless  the  use  of  the  room  makes  this  prohibitive,  and  brass  cleaning  screws 
should  be  provided  at  frequent  intervals  to  facilitate  the  removal  of  insoluble 
articles. 

The  exact  arrangement  of  waste  and  soil  pipes,  the  ventilating  of  the  system  by 
secondary  pipes,  is  so  complicated  that  its  description  is  beyond  the  scope  of  this 
work,  and  should  be  entrusted  only  to  competent  contractors  and  based  on  a 
thorough  specification. 

Where  city  drains  are  not  available  it  will  be  necessary  to  install  a  sewage 
disposal  plant  for  the  breaking  up  of  sewage  and  rendering  it  inocuous,  inoffensive, 
and  odorless. 

Modern  sewage-purification  plants  first  liquefy  the  organic  solids  in  the  sew- 
age in  tanks  in  order  to  prepare  it  for  aerating  beds,  sometimes  called  "filter 
beds." 

The  tanks  alone  are  not  sufficient.  The  changes  which  sewer  liquor  undergoes 
in  a  septic  tank  are  of  less  importance  than  the  subsequent  aeration. 

The  tanks  must  be  of  the  right  form  and  capacity  to  treat  the  amount  and  char- 
acter of  sewage  discharged  into  them.  The  tanks  appear  to  intensify  ordinary 
fermentation  or  putrefaction,  settling  a  small  portion  of  the  solids  to  the  bottom 
of  the  tank  and  breaking  up  the  remainder.  This  is  done  by  anerobic  bacteria. 
When  the  liquid  reaches  the  aerating  beds  it  is  fully  purified  by  the  anerobic 
bacteria,  which  cover  the  filtering  material  with  a  film  and  where  the  poisonous 
elements  are  changed  to  harmless  elements.  Such  aerating  filter  beds  are  usu- 
ally constructed  beneath  the  surfaces  of  the  soil,  for  this  appears  to  encourage 
bacterial  activity  and  it  entirely  removes  the  possibility  of  freezing. 

Bacterial  activity  is  largely  dependent  on  natural  warmth,  hence  a  frozen  bed 
does  little  purifying  while  it  appears  to  operate. 

The  space  occupied  by  the  filter  bed  may  be  used  for  yard  or  garden  the  same 
as  though  the  plant  were  not  there. 

Some  cities  require  an  open  aerating  bed,  and  for  such  an  exclusive  space  is 
required. 

The  bed,  like  the  tank,  must  be  given  a  certain  capacity  to  do  a  certain  work, 
but  the  bed  may  be  placed  at  some  distance  away  from  the  tank  as  conditions  on 
the  premises  demand. 

In  time  the  filtering  medium  becomes  coated  with  a  jelly-like  film,  and  in  this 
film,  or  coating,  live  the  myriad  hosts  of  bacteria.  The  poisonous  liquids  are 
rapidly  converted  and  a  harmless  liquid,  produced  and  collected,  runs  away  as 
water. 

The  final  step  in  sewage  purification  and  disposal  is  in  getting  rid  of  the  water. 
This  may  be  disposed  of  by  discharging  into  farm  drains,  streams,  or  lakes,  or  by 
absorbing  the  water  in  the  soil,  by  means  of  underground  ducts  laid  beneath  the 
surface  of  the  soil.  Such  systems  may  be  built  close  to  institutions  without  danger 
of  contamination  of  the  drinking-water  supply,  of  noisome  odors,  or  any  other 
discomfort,  but  the  plant  must  be  designed  by  experts  to  be  of  the  proper  design 


PERMANENT    INSTALLATION  95 

:in<l  capacity,  not  too  large  nor  too  small.  If  they  are  not  properly  designed,  or 
if  inadequate  in  size,  they  will  be  no  better  than  the  old-fashioned  dangerous  cess- 
pools, which  should  be  prohibited  by  law,  and  are  in  some  states. 

There  are  many  specialists  who  design  and  install  such  arrangements,  but  it  is 
well  not  to  select  the  cheapest,  for  considerable  skill,  labor,  and  material  arc 
required  to  build  an  efficient  installation.  Reliable  concerns  are:  The  Cameron- 
Wiley  Co.;  The  Ashby  House  Sewage  Disposal  Co.;  The  Andrews  Heating  Co. 

Water    Piping 

The  water-supply  system  must  be  divided  into  several  parts.  If  the  city  water 
pressure  is  not  sufficient  to  force  water  to  the  highest  outlets,  it  will  be  necessary 
t<>  install  pumps  and  tanks,  so  that  there  will  be  a  cold-water  tank  system  of  pip- 
ing for  the  upper  stories,  cold-water  city  pressure  for  the  lower  stories,  a  hot- 
water  system  under  tank  pressures.  In  institutions  having  a  system  of  refrigera- 
tion a  system  of  drinking-water  piping  should  be  installed,  and  it  is  very  important 
that  this  is  covered  with  the  most  efficient  form  of  covering  at  every  point. 

There  may  also  be  a  system  of  sterilized-water  piping,  both  hot  and  cold, 
with  sterilizers  and  tanks  in  the  power  house  or  in  a  sterilizing-room  situated  above 
the  highest  outlets. 

The  hot-water  piping  should  be  paralleled  by  a  system  of  return  pipes,  so  that 
hot  water  will  flow  from  any  faucet  immediately  after  it  is  opened;  the  return  pip- 
ing permits  of  a  constant  circulation  of  the  water  entering  the  bottom  of  the  heat- 
ing  lank  and  leaving  the  top  and  will  greatly  save  hot  water,  which  means  coal. 

A  separate  system  of  pipes  for  fire  protection  should  also  be  installed,  and  so 
situated  that  water  can  be  thrown  into  every  enclosed  space.  Unless  the  city 
requirements  demand  a  large  hose,  the  hose  should  not  be  more  than  li  inches  in 
diameter,  for  larger  hose  cannot  be  handled  to  advantage  except  by  trained  fire- 
men. 

It  is  not  possible  to  place  all  plumbing  pipes  in  shafts  or  conduits  where  they 
are  always  accessible  at  a  reasonable  expenditure,  except  where  the  plumbing  fix- 
tures are  directly  one  above  another  and  comparatively  limited  in  number.  Such 
shafts  are  expensive  and  require  considerable  space,  but,  since  the  elimination  of 
Bead  for  supply  and  waste  pipes,  the  danger  of  bursting  pipes  has  been  greatly 
reduced,  and,  whereas  it  may  cost  from  $50  to  §100  to  repair  floors  and  parti- 
tions where  they  have  been  broken  to  repair  a  broken  pipe,  it  would  probably  cost 
thousands  of  dollars  to  build  shafts  and  raceways.  Waste  and  soil  pipes  should 
be  tested  by  filling  them  with  water  to  the  top,  and  water-supply  pipes  by  subject- 
ing them  to  a  water  pressure  much  greater  than  the  normal  city  pressure  before 
they  are  enclosed  in  partitions  and  plastering. 

Plumbing    Fixtures 

Enameled  iron  fixtures  were  a  great  improvement  on  plain  iron  sinks,  planished 
copper  bath-tubs,  and  marble  wash-bowls,  but  the  gloss  of  enameled  iron  is  SOOD 
destroyed  by  scouring  soaps  and  stained  by  disinfectants  anil  solutions  used  in 
hospitals,  so  that  a  more  durable  material,  such  as  porcelain  or  chinaware,  should 
be  used  for  every  fixture,  with  the  exception  of  the  scullery  and  some  of  the  kitchen 
sinks. 

The  idea]  material  is  vitreous  chinaware,  which  is  dense,  hard,  glass-like,  noii- 
absorbent,    the   same   throughout,    and    fused   on    the   surface   to   make   the  glaze. 


96 


HOSPITAL    ARCHITECTURE 


At  present  it  is  not  made  into  large  pieces,  such  as  bath-tubs  and  large  sinks. 
There  appears  to  be  a  difficulty  in  the  burning,  consequently  the  older  form  of 
so-called  solid  porcelain  must  be  used  for  bath-tubs  and  other  large  pieces.  The 
glaze  on  such  fixtures  is  made  by  firing  a  glazing  material  on  the  mass.  This 
glaze  is  quite  easily  damaged,  and  then  exposes  the  much  softer  interior  mass, 
which  is  absorbent  and  which  blackens  and  stains.  Fixtures  of  such  material  do 
not  retain  their  original  white  color  for  many  years,  and  on  these,  as  on  enameled 
iron,  gritty  scouring  material  should  not  be  used.  Solid  porcelain  is  divided 
into  A,  B,  and  C  grades  by  the  makers.  The  A  grade  is  almost  perfect,  free  from 
flaws,  and  is  desirable  for  the  operating  department.  The  only  defects  which 
place  a  fixture  in  the  B  grade  are  small  spots  and  black  lines,  called  "checks." 
This  grade  is  very  good  for  every  fixture,  and  sometimes,  if  an  order  is  sufficiently 


Fig.  29. — Double  kitchen  sink. 

large  to  require  a  special  burning  at  the  potteries,  a  number  of  C-grade  fixtures 
can  be  used. 

The  design  of  plumbing  fixtures  is  constantly  being  improved,  consequently 
recommendations  of  certain  fixtures  have  little  permanency,  and  it  is  much  better 
that  the  purchaser  visit  the  show-rooms  of  makers  or  apply  to  them  for  their 
latest  catalogues. 

The  fashion  of  setting  the  fixtures  away  from  the  walls  was  made  necessary 
by  the  form  of  porcelain  fixtures  which  were  first  made.  They  offered  no  pro- 
tection to  the  walls,  and  these  were  either  continuously  splashed  and  washed,  there- 
by destroying  their  finish,  or  protected  by  a  marble  or  glass  covering.  The  latest 
forms  of  porcelain  fixtures  are  designed  to  be  built  into  the  walls,  and  in  the  case 
of  bath-tubs  into  the  floors,  thereby  reducing  the  number  of  spaces  which  are 
difficult  to  clean  and  inspect. 

Sinks  and  wash-bowls  are  made  with  high  backs,  which  are  in  one  piece  with  the 
sink  or  bowl,  thereby  avoiding  dirt-gathering  joints.     These  are  set  prior  to  the 


PERMANENT    INSTALLATION 


97 


plastering  and  built  into  the  walls,  greatly  reducing  the  labor  necessary  for  clean- 
liness and  affording  few  spaces  for  the  gathering  of  dirt.  The  form  of  the  fixture 
for  the  operating  department  is  not  agreed  upon  by  all  surgeons,  buf  a  deep  sink, 
about  '_'(i  by  to  inches,  appears  to  be  the  most  favored,  equipped  with  a  nickel- 
plated  stopper  actuated  by  a  handle  moving  either  right  or  left  and  with  a  high 
combination  goose-neck  supply  pipe,  the  valves  of  which  are  controlled  by  knee- 
stiri'ups,  or  foot-pedals,  and  which  are  automatically  closed  by  springs  when  the 
knee  is  withdrawn.  This  automatic  closing  is  important  to  save  water,  espe- 
cially hot  or  sterile  water,  which  means  fuel. 

The  amount  of  nickel-plated  metal  work  should  be  reduced  as  much  as  possible 
by  concealing  piping  in  the  walls,  behind  porcelain  backs,  covering  the  handles 
with  porcelain,  and  making  the  parts  which  are  below  the  fixture  top  of  brass  or 
iron,  which  can  be  painted  with  thin  enamel  paint,  which  requires  much  less  labor 


Fig.  30.— Kitchen  sink. 


to  apply  once  or  twice  a  year  than  it  docs  to  polish  the  metal  at  the  frequent 
intervals  necessary  to  keep  nickel  bright.  Inasmuch  as  constant  polishing  soon 
removes  plating,  white  metal  or  German  silver  metal  work  should  be  used  instead 
of  nickel-plated  brass  wherever  the  conditions  will  permit,  for  it  is  of  the  same 
material  throughout  without  plating. 

Figures  29-33  show  some  of  the  major  plumbing  fixtures  designed  especially 
for  hospital  service. 

Figure  2!)  shows  a  double  kitchen  sink  that  may  have  a  drain  board  on  either  or 
boih  sides.  It  is  a  convenient  affair,  easily  cleaned,  with  a  minimum  of  nickel  to 
I  <  <  p  clean,  with  the  back  set  into  the  wall,  and  is  made  of  porcelain.  There  may 
be  a  metal  stopper  at  the  bottom  or  not  as  preferred. 

Figure  :>()  is  merely  a  kitchen  sink,  to  which  a  drain  board  may  be  attached 
ii  desired.     This  sink  may  also  be  used  for  an  operating  department,  and  when 


98  HOSPITAL    ARCHITECTURE 

so  used  may  be  equipped  with  knee-action  faucet.     In  case  this  sink  is  used  in  the 
operating  department,  the  plumbing  may  also  contain  a  faucet  leading  from  the 


5^jy.i.J»8Wli»JWWw 


Fig.  31. — Bath-tub  on  concrete  pedestal  for  children's  department. 


Fig.  32.— Bath-tub  set  on  floor. 

hot-  and  cold-water  sterilizers  in  another  part  of  the  suite  to  a  faucet,  as  shown  in 
the  upper  part  of  the  illustration. 


PERMANENT    INSTALLATION 


99 


Figure  31  shows  a  bath-tub  in  the  children's  department  set  upon  a  concrete 
pedestal.  Note  the  entire  simplicity  of  arrangement,  without  cracks  or  corners 
for  dirt,  and  with  all  smooth  surfaces  for  easy  cleaning.  Note  also  the  small 
amount  of  nickel  at  the  faucets  above  the  tub.  This  tube  is  placed  so  that  the 
nurse  can  bathe  small  children  without  having  to  stoop  over  much. 

Figure  32  is  practically  a  duplicate  of  the  previous  illustration,  excepting  that 
the  tub  is  set  into  the  floor.  This  is  for  bathing  larger  children,  but  this  tub  on 
a  larger  scale  is  used  also  for  tubbing  typhoids  and  ordinary  bathing.     Every- 


Fig.  33. — :Bath-tub  set  into  wall  on  two  sides. 


thing  is  smooth  about  this  tub.  It  is  free  from  the  wall,  excepting  at  the  head. 
where  it  is  set  into  the  wall,  so  that  there  are  no  catch  places  for  dust  or  dirt.  The 
metal  parts  are  reduced  to  a  minimum,  as  in  the  previous  case. 

Figure  33  shows  another  form  of  bath-tub,  with  the  practical  repetition  of  the 
main  factors  of  the  other  tubs.  In  this  case  the  tub  is  set  into  the  wall  on  two 
sides. 

These  five  cuts  are  reproductions  of  fixtures  in  the  new  Sarah  Morris  Hospital 
for  Children,  which  is  a  part  of  the  Michael  Reese  Hospital.  The  fixtures  are 
made  by  the  L.  Wolff  Manufacturing  Co.,  of  Chicago,  and  they  are  specially 
designed  for  the  purpose  intended.  Heretofore  specially  designed  tubs,  either  as 
tn  shape,  size,  or  material,  cosl  enormously,  but  the  manufacturers  are  reaching 
a  period  in  their  processes  where  they  can  make  to  order  almost  any  set  of  fixtures 
Without  any  considerable  increase  in  cost,  which  is  a  great  satisfaction  to  the 
builders  of  institutions. 

Hot-water  faucets  should  be  of  the  compression  type,  for  these  contain  a 
leather  washer  which  is  not  destroyed  by  heat.  The  Fuller  type  of  lancet-  con- 
tain- a  rubber  ball,  which  is  hardened  and  destroyed  by  the  very  hot  water  usu- 
ally supplied  from  steam-heated  tank-. 


100 


HOSPITAL   ARCHITECTURE 


The  size  of  the  supply  pipes  and  the  size  of  the  openings  from  the  supply  fix- 
tures of  bath-tubs  should  be  much  larger  than  furnished  in  the  stock  fixtures  for 
dwellings,  in  order  to  insure  a  rapid  filling  of  the  tub. 

Nickel-plated  brass  pipe  or  white  metal  pipe  should  be  of  iron-pipe  size  and 
gauge.  If  this  is  not  stipulated,  a  very  thin  pipe,  not  heavy  enough  for  cutting 
a  good  thread,  may  be  furnished,  and  will  soon  prove  a  source  of  weakness. 

Wall  outlet  water-closets  bracketed  from  the  wall,  and  which  have  no  portion 
touching  the  floor,  present  the  advantage  of  an  unobstructed  view  for  inspec- 
tion and  insure  a  clean  floor  and  no  hidden  spaces.  Such  closets,  equipped  with 
push-button  flush  valves,  appear  to  be  more  desirable  than  the  old  type  of  tank 
closet,  whether  high  or  low,  but  the  durability  of  the  valve  depends  somewhat  upon 

the  freedom  of  the  water  from  silt  or  sand, 
|S)  for  these  cut  the  working  parts  and  soon 

cause  them  to  leak,  except  in  the  case  of 
oil-operated  valves. 

Figure  33a  shows  a  new  style  of  closet 
bowl  in  which  none  of  the  parts  reach  the 
floor.  This  is  made  by  the  L.  Wolff 
Manufacturing  Co.,  of  Chicago. 

Kitchen  and  scullery  sinks  are  sub- 
jected to  such  hard  usage  that  only  the 
most  durable  material  is  suitable.  Porce- 
lain sinks  may  be  used  only  for  drawing  of 
water,  or  possibly  the  washing  of  berries 
and  small  vegetables,  but  large  porcelain 
sinks,  like  laundry  tubs,  are  very  useful 
for  the  washing  of  potatoes  and  coarse 
vegetables. 

Slate  and  soapstone  sinks  have  internal 
angles  which  are  not  easily  kept  clean,  are 
friable,  soon  broken  by  heavy  kitchen 
utensils,  and  a  dark  color  which  may  con- 
ceal foreign  substances.  Salt-glazed  ware 
and  yellow  ware  cost  almost  as  much  as  class  C  porcelain  and  is  also  chipped  by 
heavy  utensils.  Heavy  cast  iron  is  the  most  durable  for  such  use.  Well-made 
cypress  wood  sinks  are  excellent,  but  they  must  have  brass  rims. 

The  large  and  deep  sizes  necessary  for  this  work  are  not  generally  kept  in  stock, 
but  sinks  which  measure  24  by  30  by  18  inches  in  depth,  all  inside  measurements, 
are  not  expensive,  and  should  be  obtained  on  account  of  the  durability  and  the 
facility  which  the  large  size  affords  for  rapid  and  economic  work. 

Manufacturers  of  plumbing  fixtures  make  the  height  of  sink  tops  30  inches 
from  the  floor,  the  same  height  as  an  ordinary  table.  This  height  is  not  convenient, 
for  little  work  can  be  done  by  sitting  at  the  sink,  and  it  is  back  breaking  for  stand- 
ing work,  and  it  should,  therefore,  be  required  that  special  legs  be  furnished  to 
raise  the  top  of  the  sink  to  a  height  about  35  inches  from  the  floor. 


Fig.  33a. — Wall-hanging  closet. 


VENTILATION 

The  subject  of  ventilation  in  hospitals  is  perhaps  one  of  the  broadest,  most 
important,  and  most  widely  discussed,  and  yet  one  upon  which  there  is  the  least 
unanimity  by  doctors,  hospital  managers,  engineers,  and  architects. 


PERMANENT   INSTALLATION  101 

It  is  understood  and  agreed  by  all  thai  nowhere  is  pure  air  more  essential  than 
in  ami  about  hospitals,  but  the  methods  recommended  fur  obtaining  pure  air 
conditions  arc  about  as  diverse  as  the  present  state  of  the  art  of  ventilating  will 
permit.  The  physical  and  chemic  properties  of  pure  air  and  vitiated  air  have 
lieen  studied  in  a  highly  scientific  manner  by  many  scientists,  such  as  1  >0Uglas  <  Sal- 
tan and  A.  Wynter  Hlyth,  who  explain  the  mechanism  of  air  contaminations, 
the  loss  of  gaseous  diffusion,  and  the  changes  which  take  place  in  respiration; 
and  it  is  not  necessary  to  explain  to-day  that  ventilation,  as  known,  does  not 
destroy  the  deleterious  gases,  but  dilutes  the  air,  and  in  successful  installations  the 
air  dilution  is  sufficient  to  purify  the  atmosphere  and  make  it  harmless  for  re- 
breathing. 

The  ventilation  induced  by  fireplaces  and  flues  direct  from  rooms  to  the  air 
are  helpful  in  a  very  limited  degree,  but  seldom  under  conditions  more  exacting 
than  those  of  small  residences  and  the  like.  Similarly,  drafts  induced  by  gas  jets 
or  steam  coils  placed  directly  in  flues,  while  simple  in  operation,  are  effective  to 
but  a  limited  degree  when  in  small  units,  and  when  installed  to  any  extent  may 
usually  he  more  economically  replaced  by  fans. 

Ventilating  openings  in  outer  walls  connected  with  flue  type  radiators  in  rooms 
and  air  passages  beneath  floors  or  in  connection  with  indirect  radiators  are  now 
seldom  used  in  hospital  practice,  largely  on  account  of  the  fact  that  it  is  practically 
impossible  to  insure  proper  cleanliness  in  their  use,  especially  when  adjacent  to 
dusty  roads  or  streets. 

Small  hospitals  are  designed  with  little  or  no  provision  for  ventilation,  depend- 
ence being  placed  upon  window,  transom,  and  door  arrangement  for  air  circulation. 
This,  in  many  cases,  is  considered  adequate,  but,  as  hospitals  of  larger  size  are 
considered,  the  complication  of  the  structure  itself  introduces  rooms  and  depart- 
ments that  cannot  be  readily  ventilated.  This  necessitates  special  methods  for 
introducing  air  changes. 

Prominently,  for  first  consideration,  is  the  kitchen,  which  usually  requires  fans 
to  extract  the  excess  of  heated  air.  These  fans  are  most  frequently  attached  to  a 
ventilating  flue  continued  from  the  hood  over  the  ranges.  In  large  kitchens  these 
are  frequently  supplemented  by  other  fans,  either  the  simple  disk  or  propeller  fan 
placed  in  openings  through  an  outer  wall,  or,  preferably,  the  more  positive  and 
efficient,  centrifugal  fan,  with  ducts  and  registers,  to  more  effectively  direct  air 
currents. 

In  many  cases  the  fans  are  simply  used  to  withdraw  air  from  the  kitchens,  its 
entry  being  permitted  through  windows  and  other  openings;  however,  in  many 
large  kitchens  the  fan  system  includes  fans  with  ducts  for  introducing  air  to  the 
kill  hen.  These  fans  must  necessarily  be  equipped  with  steam-heating  coils  for 
cold  weather  use. 

In  the  larger  hospitals,  toilet  rooms,  utility  rooms,  service  rooms,  and  the 
like  can  seldom  be  adequately  ventilated  by  natural  draft,  and  ordinarily,  owing 
to  their  grouping,  can  be  connected  advantageously  by  ducts  extending  up  through 
the  building  to  centrifugal  fans  in  the  attic  or  housed  above  the  roof.  The  with- 
drawal of  air  from  these  rooms  may  help  ventilate  adjacent  corridors  and  halls 
by  being  drawn  into  the  ventilated  rooms4 through  register  faces  in  the  walls  or 
doors  leading  to  the  corridors.  Often  the  doors  are  shortened  so  as  to  leave  a  nar- 
row opening  beneath  them  sufficient  for  the  air-supply  requirements.  The  doors 
to  these  rooms  art'  usually  provided  with  springs  to  keep  them  closed,  and  the 
ventilating  system  acts  most  effectively  to  prevent  odors  from  entering  halls  and 
corridors. 


102  HOSPITAL    ARCHITECTURE 

The  laundry  department  of  the  larger  hospitals  can  seldom  be  so  located  that  at 
least  one  or  two  disk  fans  may  not  be  advantageously  added  for  withdrawing  the 
heated  and  moist  air.  In  this  department,  as  in  all  others,  the  centrifugal  type 
of  fan  should  be  employed  where  it  becomes  necessary  to  use  duct  work,  either  to 
control  the  source  of  air  supply  or  to  conduct  it  to  any  distance  for  outlet. 

The  importance  of  ventilation  in  assembly  rooms,  lecture  rooms,  and  the 
like  is  now  so  fully  recognized  that  the  larger  cities  prescribe  a  legal  minimum 
limitation  of  air  supply  allowable  for  the  needs  of  audiences  as  based  on  the  seat- 
ing capacity  of  the  rooms.  Here  again,  as  size  increases,  the  possibility  of  natural 
or  window  ventilation  frequently  will  not  satisfy  the  requirements,  and  artificial 
ventilation  must  be  resorted  to.  This  usually  calls  for  air  introduction  by  means 
of  fans  and  through  duct  work.  Such  a  system  must  be  laid  out  to  avoid  objec- 
tionable drafts.     Heating  coils  are  necessarily  a  part  of  this  equipment. 

Laboratories  and  similar  rooms  usually  need  ventilation  to  carry  off  fumes 
and  gases.  In  these  locations  small  electric  fans,  placed  above  the  hoods  and 
connecting  to  outlet  ducts  or  flues,  usually  suffice.  These  fans  should  be 
especially  selected  and  constructed  to  withstand  deleterious  action  of  the 
chemic  fumes. 

Among  hospitals  of  larger  extent  the  design  must  necessarily  bring  other  rooms 
and  departments  into  the  class  where  natural  ventilation  is  inadequate,  and,  as  in 
common  with  most  power-driven  apparatus,  the  larger  ventilating  units  are  usu- 
ally more  efficient  and  satisfactory,  so  the  ventilating  needs  of  the  institution  are 
then  usually  considered  as  a  whole,  and  it  is  endeavored  to  assemble  the  various 
requirements  for  outgoing  and  incoming  air  on  as  few  fans  as  possible  by  com- 
bination and  extension  of  the  duct  work. 

There  is  no  considerable  question  raised  by  either  medical  or  other  authorities 
about  the  advisability  of  mechanically  carrying  foul  air  away  from  hospital  build- 
ings, especially  in  the  parts  of  buildings  above  referred  to. 

With  the  bringing  of  outside  air  mechanically  into  the  building,  however,  there 
arise  more  complications,  and  there  are  numerous  incidental  difficulties  and  ob- 
jectionable features  to  this  class  of  service.  Most  hospitals  must  be  located  in 
the  cities,  and  frequently  in  congested  districts,  where  the  air  is  far  from  clean,  and 
the  large  amount  of  air  which  is  always  drawn  into  a  building  by  mechanical 
ventilation  is  accompanied  by  the  introduction  of  large  quantities  of  dust.  The 
economy  of  the  labor  for  cleaning  the  building  and  the  saving  to  decorations  and 
contents  by  excluding  the  dust  and  the  air  are  considerable. 

The  air  which  constantly  passes  through  a  building  is  freed  of  a  large  percent- 
age of  its  dust  by  the  change  of  direction  and  size  of  passageways,  which  deflect 
and  affect  the  air  currents  in  the  same  manner  in  which  baffle-plates  precipitate 
chemicals  in  manufacturing  processes.  It  is,  therefore,  important  that  the  air 
intakes  are  efficiently  guarded  by  air  washers,  lest  the  whole  building  become  a 
sort  of  gigantic  air-filter,  and  it  is  fully  as  necessary  to  maintain  a  vigilant  obser- 
vation of  the  working  of  the  screens  and  air  washers  lest  they  become  inefficient, 
as  it  is  necessary  to  constantly  observe  and  cleanse  water-supply  filters  in  order  to 
be  assured  that  the  water  supply  is  reasonably  free  from  impurities. 

For  cleansing  the  air,  first,  various  types  of  screens,  and,  more  recently,  air- 
washing  devices,  which  are  virtually  artificial  rainfall  producers,  have  been  devel- 
oped in  connection  with  the  fan  outfits.  These  last  have  attained  a  high  degree 
of  efficiency,  and  the  control  of  humidity  has  been  developed  in  connection  with 
them  to  such  an  extent  that  the  quality  of  air  can  be  ordinarily  kept  equal  to,  or, 
where  required,  can  be  modified  to  be,  in  general,  more  satisfactory  than  the  exist- 


PERMANENT    INSTALLATION  103 

ant  outdoor  air  conditions.  During  the  hoi  months  the  air  may  he  cooled  to  an 
appreciable  extent  in  its  passage  through  the  cold-water  spray. 

These  systems  cannot,  however,  be  fully  100  per  cent,  efficient,  and,  further, 
in  spite  of  watchful  attendance,  they  may  at  times  be  shut  down.  Eventually, 
then,  some  considerable  dust  and  dirt  will  find  its  way  into  the  various  air  passages 
and  ducts,  and  thence  become  disagreeably  evident  at  times.  Accordingly,  the 
only  proper  duct  work  for  inlet  air  passages  in  a  hospital  is  such  that,  by  il-  size 
and  smooth  hard  interior  finish,  will  admit  of  thorough  scrubbing  and  disinfection 
in  common  with  the  rest  of  the  hospital  walls  and  fittings  as  frequently  as  inspec- 
tion shows  the  need.  This  facility  for  cleansing  should  extend  to  all  the  detail 
construction  of  the  apparatus  and  passages  in  contact  with  the  washed  air. 

No  doubt  this  method  of  construction,  if  adopted,  will  do  away  with  prac- 
tically all  the  reasonable  objections  to  mechanical  introduction  of  air  to  hospital 
rooms.  An  exception  would  be  the  operating-rooms,  where  the  air-supply  registers 
should  be  provided  with  some  form  of  efficient,  antiseptic  air-filter. 

Air  drafts  are  a  troublesome  feature  in  ventilated  rooms.  The  ideal  air  con- 
dition for  some  persons  being  still  air,  any  degree  of  air  movement  will  be  more  or 
less  strenuously  objected  to  by  them.  These  objections  can  usually  be  properly 
done  away  with  by  furnishing  the  registers  with  clampers  which  may  be  readily 
adjusted  to  suit  individual  needs. 

It  must  be  realized  that  any  extensive  ventilating  system,  or  one  in  any  way 
complete  as  a  whole,  is  quite  a  considerable  installation,  and  is  not  only  expensive 
to  install,  but  entails  continual  operative  cost.  Like  all  hospital  equipment,  it  is 
actively  in  use,  and  represents  a  continuous  outlay  to  produce  a  continuous  definite 
result ;  therefore,  careful  study  should  be  given  early  in  the  planning  of  the  hospital 
to  the  consideration  of  just  what  equipment  in  the  individual  case  is  necessary, 
what  is  advisable,  what  advantages,  what  ends  are  to  be  attained,  and  at  what 
disadvantage  and  cost. 

The  investment  and  operative  costs  must  be  carefully  weighed.  All  of  these, 
in  common  with  all  the  engineering  equipment  problems,  require  expert  considera- 
tion and  the  advice  of  those  broadly  experienced  in  the  specialized  problem  at  hand. 

Many  modern  hotels  are  equipped  with  elaborate  air-washing  and  tempering 
devices,  especially  in  their  assembly  halls  and  restaurants.  But  this  is  extremely 
costly  apparatus,  both  in  first  cost  and  maintenance,  and  no  attempt  has  been  made 
on  any  considerable  scale  to  extend  such  an  equipment  to  private  rooms  of  guests, 
with  the  exception  perhaps  of  an  isolated  "royal  suite"  in  some  fashionable  hotel. 
There  is  no  such  equipment  at  work  satisfactorily  in  any  hospital  anywhere,  and, 
until  the  art  of  mechanical  ventilation  is  farther  developed,  we  might  safely  stop 
when  we  have  provided  the  kitchens,  serving  rooms,  and  utility  rooms  with  this 
feature.  In  building  large  and  costly  hospitals  it  might  be  well  to  install  metal 
or  porcelain  ducts  of  large  size  and  a  pattern  that  can  be  reached  for  cleaning, 
so  that,  when  the  problem  of  air  washing  has  been  solved,  the  machinery  can  be 
installed  with  small  cost  and  without  disturbing  the  walls. 


REFRIGERATION 

As  the  proper  preservation  and  condition  of  foods  and  the  purity  of  water  supply 
are  of  the  utmost  importance  in  hospital  service,  so  the  refrigerating  requirements 
are  most  exacting.  The  advantages  of  refrigeration  in  hospitals  include  the  cool- 
ing of  main  kitchen  and  diet  kitchen  food-supply  boxes,  refrigeration  in  service 
rooms  located  throughout  the  hospital,  cold-storage  refrigerators  for  stocks  of  foods 


104  HOSPITAL    ARCHITECTURE 

and  supplies,  the  preparation  of  such  foods  as  ices,  ice-cream,  and  delicacies  for  the 
sick. 

In  modern  hospitals  the  service  and  similar  rooms  are  quite  commonly  served 
by  dumb-waiters,  and  located  as  nearly  as  possible  above  each  other  throughout 
the  building.  This  facilitates  the  installation  of  refrigeration  piping  to  the  boxes 
in  these  rooms,  as  pipe  shafts  can  readily  be  laid  out  for  this  purpose  in  the  parti- 
tion walls  between  them. 

The  well-known  advantages  of  artificial  or  mechanically  produced  refrigera- 
tion over  coiling  by  means  of  ice  make  this  the  method  to  be  preferred  in  any  case. 
If  the  hospital  is  small,  and  natural  ice  always  obtainable  at  low  cost,  there  may  be 
a  saving  which,  for  financial  reasons,  would  make  the  use  of  natural  ice  a  necessity. 
A  decision  in  choosing  between  the  two  methods  should  only  be  made  after  a  care- 
ful consideration,  and  after  having  obtained  expert  engineering  advice,  based 
upon  an  estimate  of  the  investment  and  operating  costs  under  the  local  conditions 
as  to  cost  of  ice,  power,  supplies,  labor,  and  equipment.  The  type  and  size  of 
refrigerating  equipment  and  the  details  of  the  machinery  proper  and  accessories 
should  be  similarly  decided. 

The  advantages  of  mechanically  produced  refrigeration  are  primarily  the  ability 
to  keep  the  various  refrigerated,  boxes  or  spaces  at  any  desired  low  temperatures 
and  to  control  these  closely,  while,  at  the  same  time,  maintaining  the  boxes  in  a 
far  more  highly  sanitary  condition,  due  to  the  ability  to  hold  them  at  a  proper 
degree  of  dryness. 

Refrigerated  drinking  water  is  readily  available  with  mechanical  refrigeration. 
The  cooled  water,  when  piped  in  a  closed  circuit  and  thus  kept  pure  and  clean, 
can,  when  refrigerated,  be  circulated  throughout  the  hospital  at  any  required 
temperature.     This  facility  has  not  been  available  with  the  use  of  natural  ice. 

The  freezing  of  the  hospital's  requirements  of  pure  ice  is  an  added  feature 
now  largely  adopted  by  most  hospitals  of  considerable  size. 

The  mechanical  refrigerating  equipment  requires  space  for  machinery,  tanks, 
and  pumps.  Adequate  space  should  be  allotted  in  a  central  location  on  the  lower 
floor,  preferably  in  or  near  the  power  plant  or  boiler-room,  and  with  electric  current 
(or  steam)  water-supply  and  drainage  readily  available. 

Of  the  several  types  of  refrigerating  machinery  that  most  commonly  in  use  is 
the  compression  system.  This  has  a  gas  compressor,  driven  by  either  motor  or 
steam  engine  as  the  conditions  of  operative  economy  may  decide.  Small  units 
usually  are  motor-driven  and  larger  ones  have  engines,  which  permit  a  greater 
economic  range  of  speed  and  capacity  throughout  varying  weather  conditions  and 
requirements. 

Ammonia  and  carbonic  anhydrid,  commonly  known  as  carbonic-acid  gas,  are 
the  refrigerating  mediums  most  commonly  employed.  The  ammonia  compres- 
sion machines  are  most  largely  in  use,  as  they  have  been  more  generally  on  the 
market  for  a  number  of  years,  and  are  built  in  a  large  variety  as  to  style  and  size 
and  by  a  large  number  of  manufacturers.  This  is  probably  on  account  of  the  fact 
that  this  machinery  is  operated  under  a  considerably  lower  pressure  than  are 
carbonic-acid  compressors,  and  thus  does  not  call  for  as  highly  specialized  design- 
ing or  factory  construction. 

The  carbonic-acid  machines,  though  not  built  in  the  largest  sizes,  have  entered 
the  field  more  largely  of  late,  especially  where  a  fear  is  expressed  of  disturbing  odors 
due  to  gas  leaks,  the  carbonic-acid  gas  being  odorless,  while  the  pungent  odor  of 
ammonia  is  well  known.  In  a  properly  designed  and  tested  plant  this  fear  need 
not  be  a  disturbing  one,  and  it  is  practically  offset  by  the  fact  that  such  leaks  as 


PERMANENT    INSTALLATION'  LOS 

may  occur  axe  commonly  small  ones,  which,  in  the  case  of  ammonia,  are  promptly 
discovered  and  made  tight,  while  the  carbonic-acid  leak  may  continue  unnoticed 
long  enough  to  cause  an  extensive  loss  of  gas  and  even  of  operative  efficiency  or 
capacity  before  discovery. 

Where  plenty  of  exhaust  steam  is  available  the  absorption  system  of  refrigera- 
tion claims  some  increased  economy  of  operation,  but  this  system,  in  the  sizes  ordi- 
narily required  by  hospitals,  has  not  been  largely  adopted,  possibly  as  the  process 
is  rather  more  involved  than  the  mechanical  compression  system,  and  not  as  readily 
kept  up  to  the  best  operative  efficiency  by  the  class  of  labor  usually  available  on 
the  hospital  force. 

As  to  comparative  operative  cost,  though  the  ammonia  compression  system  is 
considered  theoretically  somewhat  more  economic  than  the  carbonic-acid  gas, 
practically  in  the  size  of  units  and  under  the  operative  conditions  existing  in  hospital 
requirements,  the  makers  of  both  types  give  about  equal  guarantees  as  to  the  cost 
of  power  for  operation.  Theoretically,  both  the  ammonia  and  carbonic-acid  gas 
are  used  over  and  over  indefinitely,  and  there  is  supposed  to  be  no  material  expense 
attached  to  renewal  of  gases.  In  the  case  of  ammonia  this  is  approximately  true, 
because  a  leak  is  immediately  detected  by  the  odor  and  is  stopped.  There  is  no 
such  safeguard  with  carbonic  gas,  since  there  is  no  odor.  As  a  matter  of  fact,  in 
the  Michael  Reese  Hospital,  w'here  this  latter  system  is  in  operation,  the  expense  of 
gas  renewals  is  a  constant  one,  amounting  to  approximately  §300  per  year,  and  it 
is  significant  that  the  ice-machine  makers  have  developed  a  practical  monopoly 
in  the  sale  of  carbonic-acid  gas.  This  is  a  feature  of  this  system  worth  taking  into 
account. 

Refrigerating  boxes  are  cooled  by  two  methods,  termed  "direct  expansion" 
and  "brine  circulation."  In  the  first,  the  compressed  and  liquefied  ammonia  or 
carbonic  anhydrid  is  piped  directly  to  the  refrigerator  boxes,  and  there  passes 
into  the  cooling  coils  through  "expansion"  valves  with  fine  orifices  through  which 
the  fluid  is  vaporized,  and  expanding  to  a  gas  in  the  cooling  coils  becomes  very 
cold,  thus  chilling  them.  One  feature  tending  to  render  direct  expansion  in  small 
coils  impracticable  is  the  frequent  stoppage  of  the  fine  valve  orifices  by  rust,  scale, 
and  other  solids. 

Where  brine  circulation  is  adopted  the  ammonia  or  carbonic-acid  expansion 
piping  is  entirely  confined  in  a  brine  cooler  or  tank  in  the  refrigerating  machinery 
room,  and  the  brine  made  of  common  salt  or,  in  some  cases,  where  very  low  tem- 
peratures are  required,  of  calcium  chloric!,  is  then  cooled  and  thence  circulated 
throughout  the  hospital  to  the  various  refrigerator  boxes  in  a  closed  piping  circuit. 

The  valves  located  at  the  boxes  can  be  set  to  suit  the  amount  of  refrigeration 
needed  by  each,  and  thereafter  the  brine  temperature,  being  controlled  in  the 
machinery  room,  the  required  temperature  of  all  the  boxes  can  be  thus  properly 
maintained  without  more  than  the  occasional  inspection  necessary  for  the  removal 
of  frost,  which  forms  gradually  on  the  refrigerating  pipes  in  the  boxes,  thus  insula- 
ting and  rendering  them  inefficient. 

In  many  cases  where  mechanical  refrigeration  is  installed  consideration  should 
be  given  to  the  saving  in  labor,  which  is  effected  by  having  the  machinery  of  ade- 
quate capacity  to  supply  the  refrigerating  requirements  easily  when  operated  only 
through  the  daytime,  and  arranged  to  have  only  the  small  brine  circulation  pump 
in  operation  through  the  night.  This  is  one  feature  in  favor  of  brine  circulation 
instead  of  direct  expansion  system  where  refrigerating  gas  is  circulated  direct 
through  the  building. 

To  eliminate  a  considerable  loss  in  economy,  all  the  cold  piping  of  the  refrigera- 


106 


HOSPITAL    ARCHITECTURE 


ting  system  should  be  protected  by  a  heat-insulating  covering  of  the  highest  obtain- 
able quality  (Fig.  34).  Standard  coverings  are  furnished  of  compressed  cork  and 
of  wood  or  hair  felt.  In  selecting  insulation  it  must  be  kept  in  mind  that  a  con- 
siderable difference  in  first  cost  will  be  very  rapidly  outweighed  by  the  continued 
loss  of  refrigeration  due  to  the  selection  of  a  lower  quality  of  insulation. 


ASPHALT 


Fig.  34.- 


-Insulating  partition  between  refrigerator  and  main  room.     Usually  the  cork  is  placed 
above  the  tile.     The  cut  is  not  correct  in  this  particular. 


The  specifications  should  establish  a  guaranteed  result  of  refrigeration  and  a 
five-year  guarantee  against  deterioration  of  the  covering.  Pipe-covering  manu- 
facturers who  specialize  in  refrigerating  insulation  will  agree  to  such  guarantees. 


VACUUM  CLEANING 

Removal  of  dust  and  dirt  and  their  attendant  bacteria  in  a  manner  at  once 
thorough  and  with  a  minimum  of  labor  and  noise  has  long  been  an  important 
problem  in  hospital  management,  and  mechanical  vacuum  cleaning  or  sweeping 
devices  have  been  adopted  by  hospitals  as  rapidly  as  their  development  has 
brought  them  into  the  realm  of  hospital  usefulness. 

While  portable  vacuum  cleaners  or  sweeping  machines  have  been  developed 
for  use  in  residences  and  small  buildings,  the  more  exacting  requirements  of  hospi- 
tals make  it  advisable  in  all  cases  to  install  stationary  equipment  with  machines 
located  in  the  basement  or  machinery  room  and  connected  to  a  complete  vacuum- 
piping  system  extended  throughout  the  building.  Inlets,  with  openings  conve- 
niently located  throughout  the  building,  allow  of  attachment  of  cleaning  and 
sweeping  tools  by  means  of  flexible  rubber  or  steel  hose.  An  objection  to  the 
portable  vacuum  cleaners  is  that  they  discharge  the  air  into  the  rooms  which  are 
being  cleaned,  much  of  the  finer  dust  being  stirred  up  with  the  air. 

In  designing  a  layout  for  a  stationary  vacuum  cleaner  considerable  care  should 
be  given  to  the  location  of  hose-connecting  outlets,  as  long  sections  of  hose  cut  down 
the  effectiveness  of  operation  quite  rapidly.  The  opening  should  be  so  placed 
that  every  part  of  every  room  may  be  reached  by  as  short  a  hose  as  practicable. 
Hose  is  generally  furnished  in  25-  and  50-foot  lengths,  and  longer  lines  than  50 
feet,  or  possibly  75  feet,  are  hardly  to  be  recommended. 

The  tools  are  usually  furnished  in  sets  of  from  eight  to  a  dozen  kinds,  the 
different  ones  being  designed  for  cleaning  various  surfaces,  such  as  rugs,  bare 


PERMANENT    INSTALLATION  107 

floors,  walls  and  ceilings,  tapestry,  furniture,  and  clothing,  thus  individual  require- 
ments can  be  readily  met  by  proper  selection. 

The  number  of  sets  of  tools  and  hose  outfits  is  determined,  of  course,  by  the 
size  of  the  hospital.  It  is  best  to  have  only  as  many  sets  as  will  be  required  to 
(•(instantly  employ  the  operators  throughout  the  day  by  an  orderly  procedure  from 
room  to  room  in  accordance  with  some  regular  schedule. 

The  hose-connecting  pipe  openings  should  have  tight  valves  to  prevent  loss 
through  leaks.  A  pipe  system  should  be  laid  as  directly  as  possible  and  be  properly 
designed  as  to  size,  with  absolutely  smooth  interior  and  with  cleanout  openings 
at  points  sufficient  to  allow  ready  inspection  in  case  of  stoppage. 

Vacuum  machines  are  ordinarily  designated  by  size,  as  one-sweeper,  two- 
sweeper  capacity,  etc.  The  required  size  is  determined  by  the  number  of  sets  of 
tools  to  be  kept  in  use  simultaneously.  The  power  used  corresponds  to  the  work 
done  by  the  pump,  and  accordingly  the  equipment,  like  the  tools,  should  be 
selected  small  enough  in  size  to  run  nearly  continuously  with  small  power  rather 
than  intermittently  with  greater  power  requirements. 

The  vacuum-cleaning  system  operates  to  effect  the  withdrawal  of  the  dirt  and 
dust  through  the  aperture  in  the  hand  tool  along  with  a  strong  current  of  air  drawn 
into  and  through  the  hose  of  the  piping  system,  and  thence  through  dust-separating 
and  cleansing  chambers  or  tanks,  by  means  of  a  power  operated  vacuum-pro- 
ducing pump. 

The  piping  system,  as  before  described,  is  extended  from  the  various  outlet 
locations  to  the  machinery  room,  where  the  separating  receptacles  and  the  pump 
with  its  motor  are  located. 

The  piping  system  can  be  installed  under  proper  supervision  by  plumber  or 
Bteamfitting  contractors.  Hose,  fittings,  and  the  dust-separating  equipment  and 
air-pumping  machinery  are  sold  and  installed  ordinarily  by  the  manufacturers. 

As  vacuum  cleaning  is  rapidly  being  adopted  in  many  classes  of  buildings,  the 
speedy  development  of  the  field  has  brought  many  types  of  vacuum  machines 
on  the  market,  these  necessarily  varying  in  excellence  of  design  and  type. 

The  dust-collecting  receptacles  are  usually  metal  tanks  or  boxes,  ample  in  size 
to  properly  slow  down  the  air  currents,  and  equipped  with  baffles,  screens,  and  trays 
to  receive  the  dirt. 

For  further  elimination  of  dust  from  the  discharged  air  some  have  water 
Bprays  in  tanks  in  series  with  the  dry  separator,  in  which  case  water  supplies  and 
drainage  to  sewer  must  be  connected.  When  the  dry  separator  only  is  used  the 
dry-air  discharge  pipe  is  ordinarily  led  away  to  the  outdoor  air  or  to  some  flue  or 
chimney. 

In  hospital  practice  it  is  advisable,  where  possible,  to  lead  this  air  in  under 
grates  of  boilers  or  into  garbage  destructors,  so  that  the  discharged  air  may  be 
thoroughly  sterilized  and  rendered  harmless  and  the  dirt  consumed. 

Among  the  types  of  vacuum-producing  pumps  there  are  prominently  the 
reciprocating  vacuum  pump,  the  positive  rotary  pump,  and  the  fan-type  pump. 
Owing  to  the  simplicity  of  construction  and  smoothness  of  operation  the  two 
latter  types  are  much  more  prominently  in  use. 

After  deciding  upon  the  capacity,  the  selection  of  the  type  of  vacuum  machinery 
required  should  be  governed  by  a  comparison  of  the  sturdiness  of  construction, 
wearing  qualities,  smoothness  of  operation,  noiselessness,  the  economy  ot  power 
consumption  for  a  guaranteed  vacuum  produced,  and,  further,  as  to  general  thor- 
oughness and  completeness  of  design. 

The  motor  should  be  of  a  standard  high-grade  design,  preferably  mounted  with 


108  HOSPITAL    ARCHITECTURE 

the  vacuum  pump  on  a  heavy  common  metal  base  plate,  and  connected  to  it  either 
directly  or  by  a  heavy  belt  or  well-designed  noiseless  chain  drive. 

Automatic  control  switches,  which  either  shut  down  or  unload  the  machinery 
whenever  the  sweeping  tools  are  not  in  use,  are  desirable,  and  now  usually  included 
with  the  standard  equipments.  In  small  installations,  control  switches  may  be 
advantageously  located  at  each  hose  connection. 

The  wiring  for  such  motors  and  switches  should  be  of  high  grade,  installed  in 
iron  conduit  by  competent  electricians. 

Hospital  administrators  need  not  expect  to  cut  down  their  cleaning  by  other 
means  when  they  install  vacuum  cleaners.  The  same  amount  of  hand  cleaning 
will  have  to  be  done.  Moreover,  it  must  be  admitted  that  in  the  present  state  of 
the  vacuum-cleaning  art  there  is  very  much  work  that  these  cleaners  will  not  do. 
They  will  clean  rugs  and  carpets,  tapestry  curtains,  upholstered  furniture,  if  such 
unscientific  stuff  be  a  part  of  the  hospital  equipment,  and  they  will  take  much  dirt 
out  of  the  mattresses  on  the  beds  and  on  the  nurses'  couches.  They  are  not  satis- 
factory for  removing  the  dirt  from  bare  floors,  especially  wood  floors  with  cracks 
in  them,  nor  are  they  satisfactory  as  wall  cleaners,  because  the  best  tools  made 
leave  streaks  after  them  that  do  not  come  off  except  by  washing;  and,  if  we  must 
wash  after  them,  why  not  wash  without  them?  Their  usefulness  in  cleaning  radia- 
tors is  very  limited,  since  none  of  the  tools  made  get  very  far  between  the  coils, 
and  the  commercial  vacuum  will  not  draw  from  a  sufficient  distance  to  get  out 
very  much  excepting  the  surface  dust.  The  furniture  cannot  be  cleaned  by  the 
vacuum  cleaner,  whatever  the  manufacturers  say,  because  the  tools  scratch  the 
varnish  or  finish  and  soon  ruin  it. 

In  short,  the  vacuum  cleaner  is  a  most  attractive  device  theoretically,  and  has 
more  good  "talking  points"  than  almost  any  other  hospital  convenience,  especially 
that  upon  which  manufacturers  have  to  dwell — namely,  that  it  removes  the  dirt 
from  the  room  instead  of  stirring  it  up  to  settle  elsewhere.  That  would  be  true, 
if  it  did  all  the  things  claimed  for  it,  but  it  does  not  do  so. 

ELEVATORS 

Modern  hospitals,  several  stories  in  height,  are  so  largely  dependent  upon 
elevator  service  that  the  elevators  will  at  once  be  recognized  as  a  most  important 
item  of  equipment,  which  should  receive  early  consideration  in  the  planning  of  the 
building. 

The  efficiency  of  the  hospital  service  can  be  largely  influenced  by  proper 
elevator  location.  The  number  of  elevators  to  be  installed  for  a  hospital  of  given 
size  is  influenced  by  the  relative  location  of  various  departments,  the  class  of 
hospital,  the  service  offered,  and  by  special  features,  such  as  lecture  rooms,  clinic 
rooms,  and  the  like,  if  located  on  upper  floors,  and  the  influence  of  these  various 
features  should  be  carefully  estimated. 

The  larger  part  of  the  elevator  service  is  passenger  service. 

In  large  hospitals  one  freight  elevator  is  usually  installed,  or,  in  lieu  of  this, 
one  of  the  passenger  elevators,  properly  located,  has  doors  in  the  car  adapted  to 
freight  service,  to  which  it  may  at  times  be  given  over. 

In  selecting  the  type  of  elevator  the  aim  should  be  to  obtain  that  which  gives 
the  greatest  range  of  speed  combined  with  absolute  smoothness  of  running  and 
certainty  of  control.  In  general,  the  hydraulically  operated  types  of  elevator 
most  nearly  fulfil  these  conditions.  These  are,  in  general,  somewhat  more  expen- 
sive in  first  cost  than  electrically  driven  elevators,  but,  if  well  designed,  less  expen- 


PERMANENT    [NSTALLATION  109 

rive  in  upkeep.  Moderate  speeds  are  satisfactory  in  hospital  elevator  service, 
ami  electric-elevator  control  lias  been  developed  to  a  point  whore  it  is  now  reason- 
ably satisfactory  for  this  service. 

The  elevator  car  or  cab,  if  ample  in  size  to  readily  accommodate  a  wheeled 
stretcher  and  attendant  doctors  and  nurses,  is  sufficient  for  the  regular  passenger 
service.  The  laying  out  of  the  approaches  and  the  elevator  doors  should  have  in 
view  the  ready  transfer  of  patients  on  wheel  stretchers  or  in  wheel  chairs. 

One  elevator  in  large  hospitals  may,  if  properly  located,  be  advantageously 
set  aside  for  the  use  of  hospital  servants  and  those  connected  with  the  rough 
labor  about  the  building.  This  location,  in  all  probability,  would  make  advisable 
its  use  also  for  freight  purposes. 

In  smaller  hospitals  the  push-button  type  of  elevator  control,  if  installed, 
allows  of  operation  by  the  passengers  and  does  not  need  the  service  of  a  regular 
attendant.  This  is  equipped  with  automatic  starting  and  stopping  devices,  con- 
trolled entirely  by  push  buttons  at  the  elevator  doorways  and  in  the  cab.  The 
elevator  can  lie  called  to  any  floor  by  pushing  the  button  located  outside  the  door- 
way, and  the  passenger  in  the  car  can  direct  the  elevator  to  any  desired  floor  by 
pushing  a  correspondingly  numbered  button  within  the  car.  The  equipment  is 
safeguarded  automatically  to  the  extent  that  cars  cannot  be  started  or  stopped 
while  doors  are  open,  nor  can  doors  be  opened  while  the  car  is  in  motion,  nor  in  any 
case  except  at  the  landing  where  the  car  stands. 

( (nly  those  who  have  been  in  a  hospital  as  patients  appreciate  the  necessity  for 
eliminating  noises  of  every  kind,  many  of  which  persons  in  good  health  will  not 
notice,  but  which  are  extremely  annoying  to  patients,  and  especially  at  night. 

The  operation  of  an  elevator  is  attended  by  noises,  some  of  which  cannot  be 
avoided,  as  control  devices  must  make  and  break  electric  connections  by  a  snappy 
movement;  so  that  the  machine  should  be  thoroughly  enclosed  wherever  located. 
It  is  probably  least  noticeable  in  a  basement  room.  If,  however,  it  must  be 
overhead  it  should  not  stand  directly  over  a  ward,  but  in  a  tower  directly  over 
the  shaft, 

Elevator  Doors. — On  account  of  fire  hazard  elevator  doors  should  be  made  of 
metal.  Light  metal  doors  are  noisy.  They  should  be  made  of  heavy  sections  of 
steel,  and  hung  on  perfectly  turned  ball-bearing  wheels.  Heavy  solid  tracks  for 
noiseless  operation  of  the  elevators  are  essential,  and  especial  attention  to  attain 
this  end  should  be  given  the  door  construction. 

Heavy  doors  increase  the  difficulty  of  operation.  There  are  well-designed 
door  buffers  on  the  market,  also  automatic-air  or  power-driven  door  opening, 
closing,  and  locking  devices;  these,  although  an  added  expense,  are,  in  hospital 
service,  most  desirable  on  account  of  the  safety  which  they  insure.  They  can.  in 
general,  he  constructed  so  as  to  be  practically  noiseless.  The  compressed-air 
devices  cost  about  8100  per  opening;  the  Norton  elevator  door  check  about 
*'-'■">.  The  first  opens  and  closes  the  door  automatically;  the  second  closes  the  door 
automatically  and  must  he  opened  manually. 

Special  attention  should  be  given  to  requiring  a  good  set  of  tracks  and  wheels 
for  the  rolling  doors.  These  are  made  to  range  in  cost  from  a  few  dollars  to  about 
■■"-I")  a  set.  In  the  latter  the  moving  parts  are  carefully  machined  and  rolled  on  a 
Continuous  row  of  large  perfectly  turned  steel  balls,  so  that  heavy  doors  may  be 
moved  smoothly  and  easily.  The  tracks  of  cheap  hangers  are  made  either  of  stamped 
sheet  steel  or  thin  bar  iron  which  has  not  been  straightened  or  trued,  and,  although 
the  faces  of  the  wheels  may  lie  turned  on  a  lathe,  they  jump  along  the  track,  and 
thereby  cause  noise  which  is  added  to  the  hollow  sound  given  out  by  the  tracks. 


110  HOSPITAL    ARCHITECTURE 

Inasmuch  as  the  elevator  should  be  large  enough  to  carry  a  wheel  chair,  and  in 
some  cases  a  bed,  the  full  opening  of  the  door  should  be  3|  feet  wide.  This  cannot 
always  be  opened  in  a  single  door  rolling  in  one  direction,  and  because  of  this  the 
doors  can  be  made  in  two  parts,  parting  in  the  middle  of  the  opening  and  each  half 
rolling  to  either  side.  The  width  of  the  hatchway  is  sometimes  not  sufficient  to 
allow  the  installation  of  wide  elevator  doors,  unless  a  two-thirds  operating  device 
is  used.  This  moves  two  parts  of  equal  width  to  one  side  simultaneously,  and 
recjuires  a  space  or  pocket  only  one-half  the  width  of  the  door,  with  4  inches  added 
for  the  operating  device. 

The  underside  of  the  door-sill,  which  usually  projects  into  an  elevator  shaft, 
should  have  a  slanting  sheet  of  steel  secured  to  it  and  to  the  wall  below,  so  that 
the  accidental  projection  of  a  stretcher  cart  or  of  a  person's  foot  beyond  the  edge 
of  the  car  will  not  result  in  a  serious  accident.  If  the  guard  is  placed  at  a 
sufficiently  steep  angle  the  car  or  foot  will  be  pushed  away. 

If  there  are  two  openings  in  an  elevator  cab,  the  one  used  the  least  must  be  pro- 
tected by  a  door  sliding  on  the  cab  or  by  a  folding  door. 

Solid  sheet  steel  doors,  known  as  art  metal  doors,  with  polished  wire  glass  panels 
are  preferable  to  open  iron  grill  doors  on  account  of  partially  preventing  the  travel 
of  noise  from  story  to  story. 

The  best  arrangement  to  exclude  the  noise  of  elevator  travel  and  doors  from 
the  wards  is  to  arrange  a  sound  lock  or  hallway  between  the  principal  corridor 
and  the  elevator  shaft,  with  doors  at  the  corridor.  The  lock  must  be  large  enough 
to  contain  a  stretcher  car  and  several  persons  and  to  permit  of  opening  the  hinged 
doors  in  the  corridor  opening. 

Elevator  Signal  Push  Buttons. — Signal  push  buttons  at  the  elevator  doors 
should  preferably  be  designed  for  two  separate  buttons,  one  marked  "T_"P"  and 
one  marked  "DOWX."  These,  when  wired  to  annunciators  equipped  to  give 
similar  indication,  greatly  facilitate  prompt  elevator  service. 

Safety  Devices  for  Elevator. — Door-operating  devices  are  now  so  constructed 
that  they  serve  to  interlock  the  elevator  car  and  the  doors  at  each  floor  in  such  a 
manner  that  the  car  cannot  be  started  from  the  floor  unless  all  the  doors  are  locked, 
and  no  door  can  be  opened  except  when  the  car  is  stopped  and  standing  opposite  it. 

These  devices  safeguard  the  elevator  positively  from  the  most  common  cause 
of  elevator  accidents,  and  no  doubt  serve  to  save  many  lives. 

A  practical  mechanical  attachment  for  this  purpose  has  recently  been  put  on 
the  market  and  installed  in  some  hospitals.  This  is  designed  to  be  attached  to 
most  of  the  types  of  elevators  now  in  use  and  at  a  moderate  cost.  Devices  of 
this  sort  are  of  vital  necessity  in  public  buildings  of  the  hospital  type,  where  the 
class  of  passengers  and  operatives  make  carelessness  probable. 

Dumb-waiters. — Dumb-waiters  or  small  service  lifts  are  considered  essential 
in  hospital  construction.  These  are  installed  to  run  between  main  kitchens,  diet 
kitchens,  and  service  rooms  upstairs,  and  may,  in  small  hospitals,  be  hand-operated, 
but  in  large  hospitals  power-driven  dumb-waiters  are  a  necessity. 

Electric-driven  dumb-waiters  are  now  equipped  with  push-button  control,  so 
that  they  may  be  automatically  called  to  or  from  a  floor  by  means  of  push  buttons 
located  at  the  door  openings  on  all  floors.  Safety  is  assured  by  doors  being  auto- 
matically locked  while  the  car  is  moving  and  the  car  being  automatically  held  at 
a  given  floor  until  all  doors  are  shut. 

Other  Elevators. — Hand-operated  freight  lifts  of  "sidewalk  type"  are  frequently 
of  use  in  handling  supplies  to  and  from  hospital  basement  storerooms  and  the 
like. 


DIVISIONS   OF   A   GENERAL   HOSPITAL  111 

Small  hand-operated  or  electric  lifts  are  in  some  cases  useful  in  connection  with 
laundries  when  located  on  upper  floors,  but,  as  a  rule,  the  modern  demand  for 
mechanically  operated  things  almost  multiplies  the  usefulness  of  anything  that 
contemplates  hand  operation.  Besides,  these  small  openings  are  dirt  catchers, 
hard  to  clean,  and  have  been  many  times  suspected  of  conveying  infections  from 
one  floor  to  another.  They  had  better  be  left  out  and  things  carried  up  and  down 
otherwise. 

DIVISIONS  OF  A  GENERAL  HOSPITAL 

ADMINISTRATION  APARTMENTS 

The  administration  apartments  of  a  hospital  should  be  planned  to  permit 
the  patient  or  relative  to  travel  in  a  direct  line  from  the  entrance  to  the  point  of 
destination  without  returning  on  his  or  her  path.  Adjoining  the  main  entrance 
there  should  be  an  open  office  in  full  view  of  the  main  entrance  for  an  information 
bureau  or  orderly's  desk.  Behind  this  bureau  of  information  the  general  offices, 
as  bookkeeper's,  superintendent's,  and  assistant-superintendent's  offices,  should 
be  located,  so  that  if  a  visitor  has  business  with  any  of  these  employees,  he  may 
be  directed  to  them  and  observed  until  he  has  passed  into  the  respective  offices, 
or,  if  a  visitor  enters  the  hospital  and  wishes  to  call  on  a  patient  and  has  to  inquire 
in  regard  to  his  location  and  the  permissibility  of  seeing  him,  such  a  visitor  can  then 
be  directed  to  a  flight  of  stairs  or  an  elevator  within  view  of  the  information  clerk 
or  orderly,  the  intention  being  that  every  visitor  should  be  under  the  observation 
of  a  hospital  employee  or  attendant  while  in  the  building,  and  that  the  entrance 
to  the  elevator  should  be  under  the  observation  of  the  information  desk,  the 
entrances  of  the  elevators  at  the  various  floors  close  to  the  floor  nurse,  and  so  on. 
A  visitors'  parlor  should  be  close  to  the  main  entrance,  and  in  a  large  hospital  there 
should  be  two  or  three,  one  for  charity  patients  and  their  friends  and  the  other 
for  pay  patients.  These  parlors  should  connect  directly  with  toilet-rooms.  It  is 
also  desirable  to  have  a  visitors'  dining-room,  in  order  to  control  the  serving  of 
meals  to  relatives  and  friends  of  patients.  Such  a  room  will  be  an  accommodation 
to  such  persons  as  well  as  a  check  for  a  hospital.  The  size  of  the  institution  will 
govern  the  rooms  for  attendants.  Every  institution  should  have  at  least  a  bed- 
room and  sitting-room  for  the  superintendent,  and,  where  space  permits,  he 
should  have  a  dining-room  of  his  own  and  unquestionably  a  complete  bath-room. 

As  the  size  of  the  institution  dictates,  there  should  be  a  private  room  with 
private  bath  for  the  superintendent  of  nurses,  the  matron,  each  intern,  and  the 
druggist.  The  interns  ought  to  have  their  own  rooms  with  private  bath,  and 
lounging  room  and  library  in  common.  Inasmuch  as  any  one  or  more  of  these 
may  be  required  at  any  time  of  the  night  they  ought  to  be  housed  within  the  build- 
ing. For  tlu-  same  reason,  it  is  not  necessary  that  the  cooks,  laundresses,  chamber- 
maids, scrub  women,  and  other  help  of  like  nature  be  housed  on  the  grounds. 

The  advisability  of  having  the  nurses  housed  in  a  separate  building  at  some 
distance  from  the  hospital  needs  no  argument.  If  nurses  are  housed  in  the  hospital 
building  proper  it  should  be  done  only  temporarily,  as,  for  instance,  when  isolated 
with  a  patient.  The  ultimate  design  should  be  to  house  them  in  a  separate  build- 
ing. This  may  be  directly  or  closely  connected  with  the  hospital,  bu1  it  is  pref- 
erable to  have  the  building  separate  several  hundred  feet,  in  order  to  give  the 

nurses  the  benefit  of  changed  environment,  a  short  walk  through  outer  air,  freedom 
from  noise,  and  general  atmosphere  of  the  sick.      Within  the  hospital  there  should 

be  ample  toilet  facilities,  separate  toilet-rooms  for  the  nurses,  close  to  their  sta- 


112 


HOSPITAL    ARCHITECTURE 


tions;  separate  toilet-rooms  for  visitors  of  both  sexes  on  the  ground  floor;  toilet- 
room  for  office  help,  for  the  kitchen  service,  the  engineers,  and  other  male  help; 
also  close  to  the  laundry  for  the  laundresses.  The  nurses  and  other  hospital  attend- 
ants should  not  be  obliged  to  use  toilet  apparatus  used  by  patients. 

A  floor  station  for  the  nurse  in  charge  should  be  provided  on  each  floor  close 
to  the  elevator  and  in  sight  of  it,  also  centrally  and  conspicuously  located,  so  that 
the  nurse  in  charge  will  be  in  a  position  to  observe  the  corridors  of  the  floor  and  the 
elevator  openings,  so  she  may  see  visitors  and  attending  physicians  when  they 
land  on  the  floor.  A  recess  or  alcove  on  a  corridor  or  a  corner  can  be  cut  off  by  a 
light  partition,  principally  of  light  metal  framework  and  glass.  The  space  need 
be  only  large  enough  for  a  table  or  desk  and  two  or  three  chairs,  with  a  glass  deal 


Fig.  35. — Floor  station  for  nurse  in  charge  of  floor. 

plate  and  opening  through  the  glass  portion  of  the  partition  for  the  handling  of 
papers  and  small  articles.  The  space  should  contain  the  control  annunciator  or 
the  regular  annunciator  if  the  institution  is  comparatively  small.  A  photograph 
of  such  a  partition  is  shown  in  Fig.  35. 


Kitchens,   Diet   Kitchens,    Dining-rooms,    Serving-rooms,    Etc. 

The  location  of  the  kitchen  should  be  such  that  the  food  will  be  delivered 
from  the  cooking  apparatus  to  the  patient  in  the  shortest  time,  through  the  shortest 
distance,  and  with  the  least  handling.  It  is  not  always  easy  to  obtain  all  of  these 
qualifications,  and  it  is  usually  necessary  to  sacrifice  one  or  more  of  them. 

Where  rapidly  traveling  automatic  dumb-waiters  are  used  the  vertical  dis- 


DIVISIONS   OF   A   GENERAL    HOSPITAL  113 

tnnce  may  he  ignored.  In  large  public  institutions,  where  the  cost  per  patient 
need  mil  be  closely  calculated  and  extra  help  can  he  obtained  at  the  hands  of  con- 
valescent patients,  the  horizontal  distance  is  not  a  governing  factor,  for  effi- 
ciently heated  carts  can  be  obtained.  In  the  new  hospital  at  Berlin,  Germany, 
the  buildings  are  scattered  over  a  large  area,  and  the  food  is  distributed  by  a 
narrow -gauge  electric  railway,  on  which  a  small  electric  locomotive,  sufficiently 
large  to  carry  the  motorman,  is  used  to  draw  metal  food  cars  heated  by  electricity. 
It  is  also  to  be  remembered  that  the  food  must  be  distributed  unobtrusively,  and 
food  carts  must  not  be  rolled  along  corridors  used  by  visitors. 

The  main  kitchen  should  be  connected  with  the  food  dumb-waiters  or  elevators 
by  separate  corridors,  so  that  the  food  carts  can  be  moved  to  the  dumb-waiters 
or  elevators,  the  food  placed  on  these  and  discharged  from  them  in  the  several 
serving-rooms.  The  farther  away  the  dumb-waiters  are  from  the  kitchen  the 
less  likelihood  will  there  be  of  drafts  carrying  odors  to  the  upper  parts  of  the 
house.  Inasmuch  as  the  kitchen  will  probably  be  placed  either  in  the  basement  or 
on  the  uppermost  floor  of  the  hospital  building,  a  separate  corridor,  such  as  described 
above,  is  not  difficult  to  plan  and  obtain. 

Notwithstanding  that  a  kitchen  can  be  ventilated  by  mechanical  means,  it  is 
advisable  to  have  a  high  story,  from  15  to  18  feet  is  not  too  high,  if  the  kitchen 
has  a  greatest  dimension  of  40  or  50  feet,  and  if  the  kitchen  is  larger  it  should  be 
proportionately  higher.  The  high  story  insures  not  only  good  ventilation,  pro- 
vided that  the  windows  extend  close  to  the  ceiling,  but  it  also  insures  a  flood  of 
daylight  and  a  consequent  purity  and  cleanliness  of  the  food. 

The  kitchen  is  best  if  above  ground,  but,  if  it  is  necessary  to  place  the  kitchen 
in  a  basement,  not  more  than  40  per  cent,  of  its  height  should  be  below  the  level 
of  the  surrounding  ground,  and  the  walls  should  be  exposed  to  light  and  air  by  the 
construction  of  areas  of  ample  width  and  at  least  as  deep  as  the  level  of  the  base- 
ment floor. 

If  a  kitchen  is  built  as  described  above  and  thoroughly  ventilated  by  mechani- 
cal means,  there  is  no  danger  of  having  the  cooking  odors  permeate  the  building, 
and  there  appears  to  be  no  necessity  for  using  valuable  created  space  on  top  of 
a  building  for  kitchen  and  kitchen  service,  and  having  a  kitchen  on  top  of  a  build- 
ing will  remove  it  from  the  vegetable  cellars,  It  is  true  that  fully  as  efficient 
rooms  can  be  built  above  ground  to  serve  as  vegetable  cellars,  but  only  at  a  great 
expense,  and  by  using  space  more  valuable  for  other  purposes  and  leaving  cellar 
space  unused  which  has  no  other  value. 

Where  kitchens  are  on  the  top  floor  it  is  necessary  to  elevate,  not  only  all  sup- 
plies, ice  and  coal,  but  also  the  help,  and  a  separate  elevator  will  be  necessary  for 
this  purpose,  the  cost  of  which  is  discussed  in  another  section. 

The  cost  of  lowering  food  on  the  dumb-waiters  is  equal  to  the  cost  of  raising 
it,  and  seems  no  sound  argument  for  placing  a  kitchen  in  space  as  valuable  as  an 
upper  floor.  The  air-passage  ways  from  the  kitchens  to  the  remainder  of  the  build- 
ing can  be  cut  off  by  numerous  doors,  especially  if  these  are  low,  in  high  studded 
rooms. 

The  following  rooms  should  be  grouped  around  the  kitchen,  so  that  they  are 
easy  of  access  to  the  kitchen  pantry: 

A  vegetable  storeroom,  a  vegetable  preparation  room,  large  enough  also  to 
accommodate  an   ice-cream   machine  and  a   mechanical   vegetable  peeler;   a    large 

refrigerator,  divided  into  several  separate  compartments  for  meat,  fish,  milk,  butter, 
and  eggs,  ami  for  berries,  fruit,  ami  vegetables;  a  small  butcher  shop,  with  meat- 
block  adjacent  to  the  meat-box  of  the  refrigerator;  a  scullery,  with  special  deep 

c 


114  HOSPITAL    ARCHITECTURE 

sinks  for  the  cleaning  of  large  kitchen  utensils;  a  large  corridor  or  other  place  to 
store  the  food  carts;  a  dish-washing  room  and  dish  room,  also  with  special  deep 
sinks  and  possibly  a  dish-washing  machine,  this  room  to  have  dealing  counters 
in  large  openings  in  the  wall  surrounding  it,  so  that  clean  tableware  can  be  placed 
within  convenient  reach  of  the  attendants,  and  also  so  that  the  soiled  tableware 
can  be  placed  within  easy  reach  of  the  washers.  The  tableware  would  only  be  that 
used  for  charity  patients  and  the  house  help,  which  will  be  served  close  to  the 
kitchen,  such  as  the  kitchen  help,  laundresses,  and  the  help  performing  the 
coarser  labor.  The  dining-rooms  and  pantries  for  nurses,  interns,  and  others  will 
be  described  later. 

The  general  storeroom  should  be  close  to  the  kitchen.  The  room  should  be 
sufficiently  large  to  store  large  quantities  of  staple  groceries  and  other  house 
supplies  in  quantity,  such  as  soaps,  pails,  brushes,  toilet  paper,  and  should  have  a 
small  private  office  for  the  storekeeper,  with  a  railing  or  counter  between  the  room 
and  the  entrance.  The  stores,  as  required  from  time  to  time  by  the  steward  or 
cook,  are  obtained  from  this  room  on  requisitions,  as  described  in  the  sections 
on  Administration,  from  day  to  day  as  required.  In  direct  connection  with  the 
kitchen  there  should  be  a  small  storeroom,  in  which  smaller  quantities  of  kitchen 
supplies  can  be  kept. 

In  a  large  institution,  where  the  kitchen  and  other  ordinary  help  is  not  housed 
in  the  institution,  it  is  necessary  to  provide  dressing-rooms  with  lockers.  The 
room  for  the  men  would  contain  only  lockers,  wash-basins,  and  the  toilet-room; 
the  one  for  the  women,  however,  should  be  larger,  and  it  is  advisable  to  provide  a 
few  laundry  tubs,  a  laundry  dryer,  and  electric,  gas,  or  other  facilities  for  ironing, 
for,  inasmuch  as  such  women  usually  perform  their  own  laundry  work,  they  can 
do  so  between  meal  hours,  and  if  a  space  is  provided  for  them  they  will  not  use 
kitchens  and  other  unsuitable  places  for  laundry  work. 

Soup,  vegetable,  and  stock  kettles  should  not  be  connected  directly  with  a 
drain  for  sanitary  reasons,  and  also  to  avoid  the  stoppage  of  the  drains,  and  it  is  a 
good  plan  to  set  such  apparatus  in  a  row  and  enclose  the  floor  space  beneath  them 
by  a  curbing,  sloping  the  floor  slightly  toward  one  or  more  cesspools  with  remov- 
able strainers.  If  the  flooring  and  curbing  is  made  of  Terrazzo  or  other  impervi- 
ous material  which  water  will  not  affect,  the  different  apparatus  described  can  be 
cleaned  and  flushed,  and  the  water  can  fall  into  the  curb-wall  space  through  the 
valved  drain  pipes  and  escape  to  the  house  drains.  This  arrangement  affords  an 
easy  and  rapid  method  of  cleansing  such  apparatus.  The  water  from  these  curbed 
spaces  should  be  intercepted  by  catch  basins,  because  the  water  enters  the  public 
sewers. 

SERVING-ROOMS 

The  serving-rooms  should  be  centrally  located,  and  in  a  private  institution  50 
patients  per  serving-room  is  probably  a  maximum  number,  for  the  serving-room 
must  be  large  enough  to  accommodate  considerable  furniture  and  a  number  of 
people.  Each  bed  should  have  a  tray,  and  the  serving-room  should  have  a  tray 
rack  on  which  the  trays  with  tableware,  napkin,  and  silverware  can  be  placed 
when  not  in  use.  Inasmuch  as  a  tray  occupies  a  space  approximately  24  inches 
long,  and  should  have  a  clear  space  of  about  7  inches  in  height,  and  as  the  lowest 
trays  should  not  be  closer  than  18  inches  to  the  floor,  and  the  highest  cannot  be 
more  than  about  5  feet  from  the  floor,  there  is  space  for  only  six  trays  in  a  floor 
space  of  approximately  18  by  24  feet,  so  that  the  area  required  for  a  given  number 
of  trays  can  be  easily  calculated. 


DIVISIONS    OF    A   GENERAL    HOSPITAL 


115 


A  serving-room  should  have  a  small  refrigerator  for  milk,  cream,  eggs,  fruit, 
possibly  a  few  other  items,  and  a  space  for  a  ehipped-ice  receptacle,  so  that  this 
will  always  be  convenient  for  the  nurses;  a  combination  gas  and  steam  table;  a  sink 
for  washing  dishes;  a  cupboard  for  extra  tableware;  the  dumb-waiter  should  open 
directly  into  the  serving-room.  A  serving-room  11  feet  wide  by  15  feet  long  is 
probably  a  minimum  dimension,  and  it  is  not  unusual  to  have  a  serving-room  16 
by  24  feet  for  40  or  50  patients.  Refrigerators  and  cupboards  should  have  slant- 
ing tops  for  constant  observation  as  to  cleanliness. 

Refrigerators,  tables,  and  cupboards  should  stand  on  coved  bases,  the  space 
beneath  filled  solid  with  a  meager  concrete  to  avoid  all  spaces  which  might  harbor 
vermin. 


FiR.  36. — Sorvinp-rod 


Ash  is  the  most  suitable  wood  to  use  for  drain  boards  and  ot  her  woodwork  which 
is  subject  to  water,  for  it  does  not  stain.  The  tops  of  serving  tables  and  kitchen 
tallies  are  best  anil  most  solid  if  made  of  strips  of  maple,  about  f-inch  thick  and  2\ 
inches  wide  bolted  together.     Laminated  tops  of  this  kind  will  not  split  or  war]). 

The  tray  racks  in  serving-rooms  can  be  made  in  several  different  methods  of 
construction;  hardwood  is  the  cheapest,  but  most  difficult  to  maintain  properly 
varnished  and  cleansed  at  the  same  time.  A  tray  rack  can  be  made  of  steel  pipe, 
painted  with  white  enamel  paint,  10  feet  long,  and,  therefore,  large  enough  to 
accommodate  the  necessary  number  of  trays  at  a  cost  of  about  $20.  A  rack  of 
this  kind  ran  be  made  by  any  skilled  gas-  or  steainfitter. 


116  HOSPITAL   ARCHITECTURE 

Another  method  is  to  use  steel  channels  punched  with  key-hole  shaped  holes — 
such  channels  as  are  used  in  show  windows.  Metal  brackets  having  studs  which 
will  engage  in  the  holes  are  also  obtainable,  so  that  a  tray  rack  of  this  kind  can  be 
set  up  quickly  by  a  house  carpenter,  and  the  brackets  can  be  increased  in  number 
from  time  to  time  or  entirely  removed.  Figure  36  shows  a  serving-room  archi- 
tecturally equipped,  but  without  table  or  tray  racks. 

DINING-ROOMS 

The  various  classes  of  attendants  and  help  should  be  separated  and  have  their 
individual  dining-rooms,  and  the  location  of  these  should  be  as  pleasant  as  pos- 
sible to  preserve  the  self-respect  of  the  hospital  help.  The  nurses  should  have  a 
large  dining-room,  to  seat  all  those  who  can  eat  at  the  same  time;  an  ample  pantry, 
similar  to  the  serving-room,  as  described  for  patients.  The  interns  and  drug- 
gists' dining-room  should  be  served  from  a  similar  serving-room.  The  elevator 
men,  orderlies,  and  engineers'  assistants  should  have  a  separate  dining-room,  and 
if  the  institution  has  male  heads  of  scientific  departments,  such  as  resident  patholo- 
gists, another  dining-room  should  be  supplied,  perhaps  in  common  with  the  better 
class  of  office  assistants,  accountants,  artists,  x-ray  operators,  and  other  heads 
of  departments 

DIET  KITCHENS 

The  diet  kitchen  should  be  a  complete  kitchen,  with  all  of  the  equipment  of  a 
general  kitchen,  with  the  exception  of  the  larger  mechanical-cooking  apparatus; 
should  have  the  gas  range  or  ranges,  steam  table,  refrigerator,  large  kitchen  tables, 
deal  tables  in  the  partitions,  telephone  and  dumb-waiter  connections  with  the 
respective  floors.  Inasmuch  as  the  food  cooked  in  the  diet  kitchen  is  for  "special 
diet"  and  perhaps  private-room  patients,  and  since  the  trays  for  these  classes  must 
be  made  up,  if  not  entirely  prepared,  in  the  diet  kitchen  individually,  it  will  be 
necessary  to  have  a  larger  room,  constructed  to  accommodate  a  great  number  of 
individual  trays.  A  kitchen  cabinet  is  necessary  for  the  storing  of  small  quanti- 
ties of  food  supplies  and  condiments,  and  many  of  the  ready-made  cabinets  on 
the  market  can  easily  be  made  to  suit  the  purpose. 

The  diet  kitchen  should  be  of  sufficient  size  to  accommodate  a  small  class  of 
nurses  for  instruction.  A  cupboard  for  note-books  and  pencils  should  be  provided, 
also  a  blackboard  for  purposes  of  instruction  and  general  directions  and  orders. 
The  best  blackboards  are  made  of  sand-finished  green  slate  with  finished  and  beveled 
edges.  The  slate  should  be  secured  to  the  walls  by  round-headed  blue  screws,  and 
should  have  a  moulded  wooden  shelf  for  the  chalk  and  eraser. 


Many  institutions  do  not  bake  their  own  bread,  and  this  appears  to  be  an  eco- 
nomic question  to  be  decided  by  local  conditions  and  the  administration  of  the 
institution.  A  bakery  should  be  well  ventilated  and  illuminated  by  windows. 
It  need  not  be  very  large,  for  the  modern  ovens  occupy  a  space  of  about  10  by  10 
feet.  If  the  bakery  is  not  on  the  ground  floor  a  strong  floor  must  be  provided,  for 
the  brick-set  ovens  weigh  several  thousand  pounds.  The  room  should  have 
running  water  and  two  adjacent  rooms,  one  for  the  storage  of  flour  and  the  other 
for  the  storing  of  the  finished  product;  both  of  these  should  be  fairly  cool,  and  they 
do  not  require  radiation,  and  it  is  best  not  to  have  steam  pipes  pass  through  them, 
but,  if  this  is  a  necessity,  these  should  be  efficiently  covered. 


DIVISIONS   OF   A   GENERAL    hospital  117 

SUN   PARLORS 

Sun  parlors  can  be  placed  on  southerly  exposures,  but,  inasmuch  as  they  cannot 
be  targe  in  such  exposures  without  covering  windows  of  the  most  desirable  rooms, 
it  is  probably  best  to  place  sun  parlors  on  the  roofs  of  buildings.  In  this  case  an 
elevator  should  rise  directly  to  the  level  of  the  sun  parlor.  There  should  also  be 
B  toilet-room  on  the  same  floor  level.  As  much  as  possible  of  the  sun  parlor  should 
be  made  of  glass  and  of  light  steel  framing.  Possibly  it  would  be  best  to  have  the 
central  portion  of  the  roof  of  opaque  roofing,  for  the  heat  in  a  sun  parlor  is  akin 
to  the  heat  in  a  greenhouse,  and  is,  therefore,  not  pleasant  to  some  patients. 
These  probably  feel  much  better  in  a  reflected  light,  whereas  others  will  be  satis- 
fied in  sit  in  the  direct  rays  of  the  sun. 

Unless  the  roofs  of  sun  parlors  are  opaque,  the  sun  glare  will  always  be  too 
great  in  the  summer  time  for  the  comfort  of  most  patients.  Many  sun  parlors 
are  practically  out  of  commission  in  summer  on  account  of  the  great  heat. 

The  windows  must  be  screened,  and  at  the  same  time  they  should  be  made 
to  open  as  wide  as  possible.  It  is  also  advisable  to  provide  shades  so  that  the 
light  will  not  be  too  glaring,  and  so  that  during  the  hot  weather  of  summer  the 
patients  can  sit  practically  outdoors  and  still  in  the  shade. 

If  the  exhaust  pipes  of  ventilating  systems  are  close  to  a  sun  parlor,  the  piping 
should  be  extended  several  feet  above  the  roof  of  the  sun  parlor,  and  likewise  the 
ventilating  pipes  of  the  drainage  system  should  be  extended  at  least  2  feet  above 
the  tops  of  windows  in  the  sun  parlor.  If  the  roof  surface  will  permit  a  number  of 
doors  leading  to  a  platform  on  the  roof,  provided  this  is  sheltered  by  a  wall  on  the 
north  or  by  walls  on  two  or  three  sides,  such  a  place  can  be  used  to  advantage  for 
patients.  The  edges  should  lie  protected  by  high  railings,  and  no  place  should  lie 
left  unprotected,  so  that  it  will  not  be  possible  for  a  delirious  patient  to  escape  from 
the  unclosed  space. 

APARTMENTS  FOR  PATIENTS 

Location  of  Private  Rooms. — It  is  most  desirable  to  have  the  private  rooms  in 
a  separate  pavilion,  but  this  involves  the  difficulty  of  longer  distances  to  the 
operating  department  and  other  departments  of  the  hospital  for  either  the  private 
patients  or  the  ward  patients,  and  is  a  matter  which  depends  principally  on  the 
size  of  the  hospital.  If  the  institution  is  a  very  large  public  hospital,  of  such  size 
thai  the  pavilion  system  is  chosen,  it  would  then  be  quite  natural  to  provide  one 
or  more  pavilions  for  private  rooms.  In  a  small  one-building  hospital,  or  in  a  large 
city  hospital  of  only  one  building,  it  would  probably  be  most  desirable  and  best  to 
place  private  rooms  on  a  floor  by  themselves,  and,  if  the  stairs  and  elevators  are 
enclosed  and  good  discipline  maintained,  there  can  be  no  objection  to  having  large 
wards  and  private  wards  in  the  same  building. 

Having  all  of  the  private  rooms  close  together  allows  great  flexibility  in  a  general 
hospital,  inasmuch  as  many  private  rooms  can  be  used  for  any  kind  of  patient. 
If  the  private  rooms  are  placed  adjacent  to  and  in  direct  connection  with  the 
various  larger  units,  such  as  male  surgical,  male  medical,  female  surgical,  female 
medical,  and  gynecologic  wards,  their  use  would  be  rigidly  limited  to  patients 
of  that  particular  department,  and  fluctuations  in  the  number  of  cases  of  one 
kind  or  another  could  not  be  accommodated  if  the  number  exceeded  the  number 
of  private  rooms  for  the  particular  kind  of  sickness  without  mixing  the  cases  ni 
an  unsatisfactory  manner.  This  can  be  done  in  a  small  hospital,  but  would  be 
very  inconvenient  to  the  staff  and  the  management  in  a  large  institution. 


118  HOSPITAL   ARCHITECTURE 

A  small  number  of  private  rooms  closely  connected  with  the  wards  will  be  useful 
in  a  large  institution  for  patients  who  can  pay  a  nominal  fee,  or  who  are  so  ill  as  to 
require  practical  isolation. 

Details  of  Private  Rooms. — Private  rooms  may  vary  in  size  in  proportion  to 
the  proposed  price,  but  the  minimum  size  should  not  be  less  than  11  by  15  feet, 
and  the  management  of  many  hospitals  insist  on  having  every  private  room  suffi- 
ciently large  to  accommodate  two  beds  if  necessary,  and  this  will  require  that  the 
dimensions  are  not  less  than  12  by  16  feet.  It  is  well  to  arrange  the  door  and 
window  adjacent  to  one  of  the  longer  walls,  so  that  the  head  of  the  bed  will  not 
be  in  a  draft.  The  doors  should  be  3  feet  4  inches  in  width  to  permit  the  moving 
of  the  standard  3-feet  hospital  bed  from  one  room  to  another.  The  general  illumi- 
nation of  the  room  should  be  obtained  by  an  inverted  reflector,  such  as  the  x-ray 
system,  and  this  fixture  should  be  placed  in  the  center  of  the  ceiling,  low  down  and 
controlled  by  a  switch  at  the  bed.  There  should  also  be  a  bracket  outlet  over  the 
head  of  the  bed  controlled  by  an  extension  cord  switch  which  the  patient  can  control. 

Every  private  room  should  have  at  least  a  wash-bowl,  with  running  hot  and  cold 
water;  also,  if  possible,  a  water-closet. 

At  a  height  of  2  feet  6  inches  from  the  floor,  and  adjacent  to  the  bed,  there  should 
be  an  outlet  box  for  the  portable  table  lamp,  and  another  for  portable  examina- 
tion light  on  a  cord,  the  table  lamp  and  the  examination  light  to  be  brought  by  the 
nurse  as  the  patient  or  physician  requires.  The  receptacle  for  a  portable  telephone 
should  be  placed  in  the  wall  at  the  same  time  and  adjacent  to  the  two  electric-cur- 
rent receptacles,  and  also  arranged  and  finished  in  a  similar  manner;  the  tele- 
phone to  be  of  the  portable  type  with  a  cord  and  plug,  to  be  brought  into  the  room 
and  connected  only  when  permitted  by  the  nurse.  The  medical  profession  is 
beginning  to  object,  however,  to  portable  telephones,  on  the  ground  that  they 
may  carry  infections  from  a  patient  suffering  from  one  disease  to  a  patient 
already  sick  with  something  else.  There  should  also  be  a  receptacle  similar  to 
those  described,  and  at  the  same  elevation  from  the  floor,  for  the  signal  system, 
with  a  cord  and  push  in  the  control  of  the  patient.  Care  must  be  exercised  in 
obtaining  keys  or  sockets  M'hich  cannot  be  accidentally  interchanged  with  the 
electric-lighting  socket,  and  for  this  reason  it  would  probably  be  best  to  attach 
the  signal  cord  permanently  to  the  wall  plate. 

In  many  places  no  provision  has  been  made  to  hang  the  signal  cord  when  not  in 
use.  It,  therefore,  would  be  well  to  obtain  a  push  with  a  ring  secured  to  same  and 
a  small  brass  hook  on  the  wall  or  on  the  lighting  bracket  over  the  bed. 

The  question  of  having  a  private  clothes  closet,  or  not  having  one,  has  been 
much  discussed,  and  some  hospital  boards  believe  them  sanitary  and  that  no  good 
private  room  should  be  without  a  closet;  again,  other  hospital  boards  refuse  to  have 
them,  and  maintain  that  a  patient  should  come  to  a  hospital  with  only  one  change 
of  clothing,  and  that  these  should  be  kept  in  metal  lockers  in  a  general  locker- 
room  and  returned  to  the  patient  when  required. 

The  closet  adds  a  number  of  additional  corners  and  surfaces  which  increase  the 
labor  of  cleansing,  but  there  should  be  no  danger  if  maintained  in  a  sanitary  condi- 
tion. Inasmuch  as  but  little  clothing  need  be  stored  in  them,  it  is  best  to  build  a 
false  ceiling  immediately  above  the  door,  cutting  off  a  number  of  feet  of  useless 
space  and  space  which  is  difficult  to  clean  and  an  unnecessary  first  cost  and  an 
unnecessary  cost  of  maintenance. 

The  stud  height  of  all  private  rooms  and  also  the  wards  must  be  well  considered. 
A  high  stud  is  naturally  desirable  for  a  large  room,  such  as  a  ward,  whereas  the 
same  height  appears  disproportionate  and  objectionable  for  a  private  room.     Fif- 


DIVISION'S   OF   A   GENERAL   HOSPITAL  119 

teen  feet  for  a  ward  height  is  not  too  great,  but  it  will  not  do  for  a  room  11  feet 
wide  and  15  feet  long,  .so  that  a  compromise  must  be  made  and  a  balance  struck 
by  the  architect,  based  on  sound  judgment,  to  ascertain  the  height  of  stud  which 
will  be  the  most  suitable  and  also  the  least  objectionable  for  all  the  different  kinds 
of  rooms. 

Inasmuch  as  the  floor  area  and  cubic  contents  of  the  room  is  fixed  by  law  in 
many  localities  these  two  factors  must  be  considered.  No  less  than  80  square 
feet  should  be  allowed  for  each  bed,  so  that  a  room  of  10  by  16  feet  may  be  used 
for  two  beds,  but  as  the  cubic  contents  per  patient  should  not  be  less  than  1200 
cubic  feet,  such  a  room  would  then  require  a  stud  of  15  feet,  but,  as  this  height  of 
stud  for  so  small  a  room  is  undesirable,  it  would  be  better  to  increase  the  floor  area, 
but,  inasmuch  as  increasing  the  floor  area  involves  greater  expense  than  increasing 
the  stud  height,  this  matter  must  be  carefully  considered. 

A  high  studded  room  may  appear  more  airy  than  one  of  a  lower  stud  height, 
but  the  difference  in  temperature  in  the  air  of  the  various  heights  in  the  higher 
room  probably  interposes  greater  difficulties  in  easy  ventilation.  The  appear- 
ance of  a  high  small  room  is  very  unsatisfactory,  and  especially  when  viewed 
from  the  bed. 

The  electric-light  plug  outlets,  telephone  outlet,  and  signal  cord  should  be  on 
the  side  of  the  bed  nearest  the  door,  so  that  the  nurse  will  not  be  obliged  to  walk 
around  the  end  of  the  bed. 

The  head  of  the  beds  should  be  placed  about  1  foot  from  the  wall,  so  as  to 
place  the  patient's  head  in  a  zone  having  sufficient  circulation  of  air.  The  air 
close  to  the  wall  is  frequently  stagnant.  A  lounge  is  often  desirable,  and  is  then 
best  placed  opposite  the  foot  of  the  bed,  allowing  a  passageway  of  2\  feet,  also  2§ 
feet  for  the  lounge,  65  feet  for  the  bed,  and  1  foot  at  the  head  of  the  bed  requires  a 
width  of  Yl\  feet. 

Fine  large  rooms  in  the  best  obtainable  proportion  with  openings  spaced  har- 
moniously, so  that  the  effect  will  be  that  of  a  refined  private  dwelling  or  hotel,  will 
bring  a  large  return.  The  entire  furnishing  of  such  rooms  should  be  of  richer 
materials,  of  good  proportion,  good  design,  but  the  detailing  should  be  a  com- 
promise between  hospital  details  and  dwelling-house  details.  Some  of  the  effect 
should  be  obtained  by  flat  decorations;  that  is,  painted  work.  A  room  25  feet 
square  will  bring  a  proportionate  return,  and  these  rooms  should  be  arranged  so 
that  one  or  more  can  be  occupied  as  a  suite.  Suites  of  sitting-room,  bed-room,  bath- 
room, and  clothes  closet  should  be  planned;  also  suites  of  the  same  number  of  rooms 
with  an  additional  bed-room  for  parent,  wife,  or  husband  of  the  patient.  Such 
rooms  should  have  every  modern  convenience. 

The  window-sills  of  private  rooms  should  not  be  so  high  that  the  view  of  a 
patient  recumbent  on  a  bed  is  restricted  too  much,  but  the  height  of  the  sill  must 
lie  compatible  with  safety. 

Private  Wards. — Rooms  for  two  or  more  patients,  each  paying  less  than  the 
cost  of  a  private  room,  are  termed  "private  wards."  These  frequently  have  two, 
three,  four,  five,  or  six,  but  seldom  a  greater  number,  of  beds.  In  arrangement 
tiny  do  not  differ  from  the  public  wards.  The  patient  can  obtain  a  little  more 
privacy,  ami  sometimes  selected  patients  may  be  grouped  according  to  their  social 
status,  the  diseases  from  which  they  suffer,  or  their  behavior. 

Public  or  Charity  Wards. — The  number  of  beds  governing  the  phrase  "a  large 
ward"  is  indefinite.    The  Hotel  Dieu  in  Paris  contained  a  ward  of  several  hundred 

beds,  and  wards  with  a  large  number  of  beds  were  no1  Uncommon  in  the  middle  of 

the  last  century,  but  the  tendency  has  been  to  decrease  the  number,  so  thai  a  ward 


120  HOSPITAL    ARCHITECTURE 

of  25  beds  is  considered  a  large  ward  to-day,  and,  in  view  of  the  psychologic  effect 
on  the  patient,  it  is  probably  well  that  not  too  many  beds  are  placed  in  one  ward. 
Each  ward  should  have  direct  access  to  its  toilet-room  and  bath-room.  A  wash- 
stand  for  the  use  of  the  attending  physician  in  the  middle  of  the  ward  is  a  desirable 
adjunct  to  the  room.  Its  benefit  to  the  patients  is  obvious,  when  one  considers 
that  the  physician  may  examine  from  a  dozen  to  twenty-five  different  kinds  of 
cases. 

The  form  of  illumination  for  the  general  wards,  in  which  the  illuminating  bodies 
are  concealed  and  where  the  intensity  of  the  light  can  be  controlled,  is  almost  a 
necessity  in  a  ward,  in  order  to  save  the  patients  from  looking  at  intense  points 
of  light.  This  result  can  be  obtained  by  using  inverted  reflectors  and  Tungsten 
lamps,  reflecting  the  light  on  a  light-colored  ceiling.  Strong  illumination  can  be 
obtained  by  this  method  and  also  a  dimmed  illumination  for  the  sleeping  hours. 
Where  the  inverted  reflectors  are  not  in  use  a  rheostat  or  stage  dimmer  can  be 
installed,  and  the  voltage  produced  to  so  low  a  point  that  the  filaments  in  the 
lamps  will  only  glow  and  afford  the  nurse  sufficient  illumination  to  pass  around  the 
room.  For  special  illumination  a  plug  outlet  should  be  provided  at  each  bed,  as 
described  for  the  private  rooms,  so  that  the  nurse  accompanying  the  staff  physician 
can  carry  an  examination  light  with  a  cord  and  plug,  or,  in  special  cases,  a  portable 
lamp  can  be  placed  on  the  bedside  table.  The  signal  system,  cords,  and  pushes 
should  also  be  provided  for  each  bed  as  for  the  private  rooms.  If  it  is  necessary  to 
economize,  the  light  sockets  can  be  spaced  so  that  one  will  serve  two  beds. 

The  windows  should  be  spaced  in  such  a  manner  that  the  head  of  each  bed  will 
be  at  a  pier,  and  it  is  better  to  have  a  window  each  side  of  each  bed  than  it  is  to 
have  two  beds  on  one  pier.  It  is  also  desirable  to  have  the  beds  placed  so  that  as 
few  as  possible  of  the  patients  will  be  obliged  to  look  toward  the  windows  when 
lying  in  normal  positions. 

The  floors  of  wards  should  not  be  of  ordinary  matched  wood.  Linoleum  is 
probably  the  best  material.  A  fireplace  in  the  ward  is  a  cheerful  addition,  and 
further  it  will  assist  in  the  ventilation. 

The  equipment  and  special  features  of  all  these  administrative  units  of  the 
hospital  are  discussed  more  in  detail  under  the  sections  on  Equipment. 

INFECTIOUS  DEPARTMENT 

The  building  for  infectious  cases  should  contain  several  suites,  each  a  unit 
in  itself,  divided  into  a  room  for  the  patient  or  patients,  a  private  quiet  room,  a 
room  for  the  nurse,  and  a  toilet-room  and  bath  for  the  patient  and  another  for 
the  nurse;  small  entry  and  small  kitchen  or  service-room. 

Each  of  these  units  should  be  completely  separated  from  the  other  and  have 
an  independent  entrance  from  the  outer  air.  The  nature  of  the  ground  where 
the  building  is  erected  may  make  it  necessary  to  begin  the  foundations  at  some 
distance  below  the  surface  of  the  ground,  so  that  it  will  be  more  economic  to  use 
the  space  created  by  the  foundations  below  the  first  floor  than  it  would  be  to  build 
entirely  above  the  ground. 

The  cases  are  taken  into  the  separate  units  by  the  routes  marked  "entrances," 
and  attending  medical  men  enter  the  first  one  by  the  same  route  and  leave  by  the 
door  marked  "exit"  and  pass  to  the  basement,  leaving  their  infected  garments  in 
the  sterilizing-room,  pass  through  the  bath-room,  then  to  the  dressing-room,  where 
they  will  find  sterilized  clothing,  from  which  room  they  can  enter  the  lounging- 
room  and  remain  there  and  leave  the  institution  with  safety  to  others,  but  if  there 


DIVISIONS   OF   A   GENERAL   HOSPITAL  121 

are  different  kinds  of  ease.-  in  the  different  units  the  medical  men  will  follow  this 
routine  for  each  kind  of  disease.  When  the  patient  has  recovered  and  is  ready 
to  leave  the  building,  the  patient  and  nurse  must  follow  the  same  route  to  the 
basement  and  enter  the  separated  bath  departments,  where  they  will  find  clean 
clothing,  after  which  they  can  also  leave  the  institution  with  safety.  The  windows 
to  the  entry  and  to  the  kitchen  of  each  suite  should  be  arranged  so  that  packages 
and  vessels  can  easily  he  passed  in  and  out.  Food  can  be  brought  to  the  kitchen 
from  the  main  hospital  kitchen;  the  dishes  and  vessels  can  be  sterilized  in  the 
kitchen  and  placed  on  the  outside  of  the  window-sill,  which  should  be  specially 
wide  and  suitable  for  the  purpose. 

The  wards  should  have  a  set  of  adjustable  pipe  posts,  rods,  and  canvas  curtains, 
so  that  the  patients  can  be  screened  from  each  other  if  this  is  found  desirable. 

A  large  hospital  for  contagious  diseases  may  have  its  corridors  arranged  with 
doors  opposite  each  room  or  at  least  frequent  intervals,  which  can  be  closed  and 
sealed,  so  as  to  increase  the  number  of  beds  for  one  disease  and  decrease  those  of 
another,  to  accommodate  the  fluctuating  number  of  cases  of  the  diseases,  on  the 
same  principle  which  has  frequently  been  applied  in  apartment  houses  to  provide 
elasticity  in  the  number  of  bedrooms  available  for  apartments. 

Inasmuch  as  this  portion  of  a  hospital  is  not  used  much,  and  may  stand  for 
months  and  years  without  being  used,  it  should  be  built  as  economically  as  will  be 
compatible  with  safety  and  durability.  Thin  solid  plaster  partitions,  enameled 
iron  plumbing,  anil  painted  Portland  cement  floors  will  suffice. 

The  technic  and  equipment  of  an  isolation  department  are  discussed  under  the 
section  on  Isolation  and  Disinfection. 

CHILDRENS'  HOSPITAL 

For  several  reasons  explained  on  the  following  pages  a  children's  hospital 
should  not  be  directly  connected  with  a  hospital  for  adults.  The  isolation  of  the 
patients  in  a  children's  hospital  must  be  more  complete,  and  is  a  necessity  on 
account  of  the  communicable  nature  of  childrens'  diseases  from  one  to  another 
and  on  account  of  their  peculiar  liability  to  secondary  infections.  Their  resistance 
to  such  infections  is  lowered  by  wasting  disease. 

Perfect  isolation  is  easily  obtainable  in  a  large  institution  built  on  the  cottage 
plan,  and  can  also  be  maintained  in  a  pavilion  plan,  but  it  is  more  difficult  to 
accomplish  this  in  a  small  hospital  in  which  all  of  the  patients  must  be  housed  in 
one  building.  This  is  likewise  the  case  in  the  usual  city  hospital  built  on  the  block 
plan.  Small  hospitals  and  city  hospitals  should  be  designed  and  equipped  SO  that 
t h- ■>  can  be  divided  into  separate  units  by  closing  doors  which  are  normally  con- 
cealed in  recesses  across  corridors  and  by  sealing  the  joints. 

Many  of  the  rooms  should  have  French  windows  opening  to  exterior  porches, 
so  that  the  isolated  portions  of  the  building  can  be  served  by  way  of  stair-  open  to 
the  ail-. 

The  institution  must  be  divided  up  into  as  many  well-separated  units  as  pos- 
sible, to  provide  lor  partial  isolation  of  different  classes  of  diseases.  Surgical 
(clean  and  pus),  medical,  skin,  gastro-intestinal  diseases,  and  the  specialties,  eye, 

ear,  nose,  and  throat,  etc. 

There  must  be  ample  provision  for  the  isolation  of  patients  in  small  wards  and 
single  rooms. 

The  unit  measurements  of  the  architectural  features  should  also  differ  in  a 
hospital  for  children  from  those  in  a  hospital  for  adults,  ami  it  is  a  mistake  to  attempt 


122  HOSPITAL   ARCHITECTURE 

to  maintain  the  same  unit  measurements  of  floor,  window,  and  air  space.  Inas- 
much as  the  childrens'  beds  are  the  smaller,  the  window  spacing  should  be  in  pro- 
portion, the  window-sills  ought  to  be  lower,  and  the  stories  need  not  be  as  high,  for 
their  breathing  capacity  does  not  require  as  much  initial  air  space.  The  stairs 
should  have  a  lower  rise  and  many  other  details  require  special  treatment. 

Authorities  differ  as  to  the  patients'  ages.  They  are  usually  from  birth  to  about 
twelve  years.  There  are  those  who  claim  that  the  second  year  should  be  the  divid- 
ing line.  It  is  conservative  to  say  that  the  infants  of  one  year  and  under  should 
occupy  separate  rooms,  and  in  large  institutions,  where  it  is  possible,  they  should 
have  separate  buildings,  for  they  require  separate  isolation  in  some  of  their  sick- 
nesses, and  the  temperature  of  the  rooms  should  be  much  higher  for  them  than  for 
older  children;  also  the  diet  is  different  and  a  separate  kitchen  is  desirable. 

The  medical  staff  must  decide  if  there  shall  be  separate  departments  for  medi- 
cal and  surgical  patients,  or  if  these  shall  be  mingled  in  the  same  wards.  It  is 
probably  better  to  separate  these  services  if  the  size  of  the  institution  permits. 

There  should  be  separate  wards  for  infants,  others  for  children  of  two  to  five 
or  six  years,  and  still  others  for  those  from  six  to  twelve  years,  and  these  latter 
must  be  divided  according  to  sex. 

Wards  for  children  should  be  smaller  than  those  for  adults,  probably  not  over 
10  beds.  Advantages  of  the  small  wards  are:  there  can  be  better  separation  of 
service,  age,  sex,  and  of  cases  according  to  severity  and  type  of  disease;  also,  epi- 
demics are  checked  quicker,  and  are  not  likely  to  extend  so  far  when  only  a  small 
number  of  patients  have  been  exposed. 

There  is  a  constant  possibility  that  measles,  mumps,  whooping-cough,  scarlet 
fever,  and  other  diseases  may  break  out  and  infect  all  of  the  exposed  children, 
which  is  the  strongest  argument  in  favor  of  small  wards,  and  the  important  point 
to  consider  in  arranging  a  hospital  for  children  different  from  a  hospital  for  adults. 

The  wards  for  children  up  to  two  or  three  years  of  age  should  be  arranged  to 
permit  isolation  more  rigid  than  is  necessary  for  older  children.  In  the  case  where 
the  childrens'  department  is  part  of  a  general  hospital  the  age  limit  may  be  placed 
at  seven  years,  but,  where  it  is  a  separate  institution,  children  up  to  twelve  or 
fourteen  years  of  age  are  generally  admitted. 

There  must  be  quiet  rooms  for  nervous  cases  and  for  critically  sick  children, 
so  that  their  parents  can  be  with  them. 

The  question  of  how  many  children  to  have  in  one  room  is  of  great  import- 
ance, and  experience  has  demonstrated  that  the  incidence  of  an  epidemic  usually 
does  not  bear  relation  to  the  size  and  position  of  the  room.  In  place  of  a  small  room 
the  box  system  has  been  inaugurated,  by  which  is  meant  the  division  of  the  ward 
by  means  of  complete  and  incomplete  glass  partitions  into  small  rooms,  each  room 
containing  one  bed.  Some  of  these  boxes  are  of  iron  and  glass  extending  from  floor 
to  ceiling,  each  box  a  complete  room;  in  others,  the  partitions  do  not  close  the  room 
toward  the  center  of  the  ward.  Again,  in  some  of  them  the  partitions  reach  from 
the  floor  almost  to  the  ceiling,  and  in  still  others  they  reach  neither  the  ceiling  nor 
the  floor.  Authorities  agree  that  the  only  advantage  in  the  closed  partition  is  to 
make  the  nurse  more  careful,  and  if  it  were  possible  to  make  her  so  without  this 
reminder,  the  partitions  would  not  be  required,  for  each  bed  should  have  a  number 
and  a  corresponding  locker.  Everything  used  for  the  infant,  including  bed,  table, 
tray,  cup,  dishes,  hair-brush,  comb,  powder-box,  even  toys,  should  have  the  same 
number. 

These  "boxes"  are  more  appropriately  discussed  in  the  sections  on  Isolation 
and  Disinfection.     It  is  certainly  proper  to  maintain  as  great  an  amount  of  sepa- 


divisions  OF   A   GENERAL   HOSPITAL  123 

ration  between  the  sick  as  possible,  but  it  has  been  found  that  nurses  are  very 
prone  to  rely  wholly  on  such  "constructive"  isolation  for  safety,  and  so  let  down 
the  bars  of  carefulness  and  strict  cleanliness. 

In  planning  a  children's  hospital,  air  space  and  sunlight  for  the  children  are  the 
most  important  points.  The  rooms  should  be  well  ventilated  and  sunny  and  yet 
the  latter  can  be  overdone. 

A  children's  hospital  should  have  a  number  of  separate  entrances — namely, 
a  principal  entrance  for  physicians,  and  possibly  parents  and  friends  of  pay 
patients,  directors,  and  auxiliary  societies.  This  entrance  should  not  be  used  for 
receiving  prospective  patients;  and,  for  administration  reasons,  it  is  best  to  have 
the  entrance  section  connected  to  the  hospital  proper  by  only  one  door,  connecting 
with  the  stair  and  elevator  hall,  under  the  control  of  the  person  in  charge,  for  it  is 
more  necessary  with  children  than  with  adults  that  they  be  protected  and  have  no 
contact  with  any  one  but  the  physicians,  interns,  and  nurses,  and  occasionally 
with  parents  and  friends,  and  this  should  be  only  on  occasions  when  the  physician 
determines  that  there  is  no  danger.  The  entrances  should  be  so  arranged  that 
visiting  can  be  absolutely  controlled  and  prevented  if  necessary. 

The  main  entrance  should  have  a  waiting  space  proportionate  in  size  to  the 
hospital  itself,  one  reception-room  with  women's  toilet-room,  another  for  men, 
and  a  room  with  lockers  for  the  attending  physicians  with  an  adjoining  toilet-room. 
There  should  be  a  separate  entrance  leading  to  the  kitchen  and  storerooms  for  the 
trades  people. 

The  most  important  entrance,  however,  is  the  one  for  the  reception  of  prospec- 
tive patients.  The  vestibule  should  open  into  a  commodious  waiting-room,  where 
the  applicants  need  not  be  huddled  together  or  in  too  close  contact.  A  study  of 
Fig.  37  will  quickly  explain  the  arrangement  described  below: 

A  hallway  from  the  waiting-room  should  lead  to  at  least  two  examination 
rooms,  one  of  these  arranged  so  that  it  may  be  used  as  a  surgical  dressing  or  exami- 
nation room,  and  both  of  them  connected  to  disrobing  booths,  so  that  the  attend- 
ing physicians'  time  can  be  economized.  Sinks  with  running  water  should  be  in 
each  one.  Two  rooms  will  be  enough  for  a  hospital  of  25  patients.  A  laboratory 
should  be  adjacent  to  the  examination  rooms,  which  need  not  be  more  than  6  or 
7  feet  in  width  and  12  to  15  feet  in  length.  Inasmuch  as  an  applicant  may  be 
Buffering  with  diphtheria  or  other  contagious  disease,  and  cannot  be  received  in 
the  hospital,  one  or  two  small  rooms  immediately  adjacent  to  the  entrance  should 
be  maintained,  in  which  such  a  patient  with  mother  or  relative  can  be  comfortably 
isolated  until  arrangements  can  be  made  to  take  the  patient  to  a  hospital  for  con- 
tagious diseases  or  back  to  its  home.  These  rooms  need  not  exceed  7  by  9  feet, 
but  should  have  a  window,  and  each  one  should  connect  with  a  separate  small 
toilet-room,  containing  a  water-closet  and  wash-stand  with  running  water.  Some- 
times several  hours  will  pass  before  the  patient  ran  be  taken  away,  so  that  it  is 
necessary  to  have  such  an  arrangement  ready  for  instant  use.  The  finish  and 
fittings  of  such  rooms  should  be  very  simple,  so  that  they  can  be  easily  disinfected 
alter  use. 

After  it  is  decided  to  accept  a  child  it  should  be  taken  from  the  examination 
room  directly  to  the  entry  bath,  from  which  the  child's  clothing  can  be  dropped 
into  the  disinfecting  or  sterilizing-room  in  the  basement  through  a  trap-door  in 
the  Boor,  and  not  through  a  long  chute  with  walls  which  may  become  infected. 
The  entry  bath-room  has  a  linen  closet,  so  that  the  child  can  be  clothed  with  hospi- 
tal clothing  and  taken  from  there  t<>  the  observation  department,  which  should 
be  isolated  from  all  other  parts  of  the  building.     The  patient's  clothing  should  be 


124 


HOSPITAL   ARCHITECTURE 


DIVISIONS    OF    A   GENEUAL    HOSPITAL 


125 


passed  directly  to  a  stcrilizing-room,  where  the  clothing  can  be  disinfected,  bundled, 
tagged,  and  stored.  In  sonic  in>titutions  the  child's  clothing  is  returned  to  the 
\\  ailing  parent,  so  that  the  labor  of  tagging  and  storing  and  possibly  loss  is  avoided. 
Alter  a  child  is  accepted  it  should  be  placed  in  an  observation  department,  iso- 
lated from  all  other  rooms  in  the  building.  To  make  the  isolation  effective  each 
child  should  have  a  separate  complete  small  room,  where  it  can  remain  isolated 
for  a  proper  period  to  determine  if  it  may  be  safely  placed  among  the  children  in 
the  hospital  proper.  Each  such  room  should  contain  running  hot  and  cold  water. 
Figure  08  shows  a  series  of  these  observation  rooms  with  glass  partitions  between, 
so  that  a  nurse  may  see  through  the  whole  suite  at  once. 


k 


m 


series  of  observation  rooms  with  glass  partitions  between. 


The  observation  department  will  require  all  of  the  auxiliary  rooms  necessary 
t<>  make  it  a  complete  unit,  such  as  a  serving-room,  milk  kitchen,  linen  closet, 
cart  closet,  a  slop-sink  room,  also  a  nurses'  sleeping-room  with  bath. 

General  baths  are  not  necessary  in  this  suite,  as  the  children  are  bathed  in  bed, 
and  portable  commodes  are  sufficient  instead  of  ordinary  toilet-rooms. 

'l'ln'  observation  department  should  have  one  or  more  complete  suites  or  unit-. 

where  a  patient  and  a  nurse  can  both  be  completely  isolated  if  it  should  become 

ry,  such  suites  to  include  a  patients'  room,  a  nurses'  room,  and  a  nurses' 

bath-room  with  tub.  closet,  and  wash-stand.     If  necessary,  one  main  room  for 

both  patient  and  nurse  will  do.  but  the  other  factor-  are  necessities. 

In  connection  with  the  general  wards  of  the  hospital,  balconies  are  of  the 
greatest  importance,  but  their  value  is  measured  more  by  the  ease  of  access  than 
by  their  size  and  exposure  (Figs.  39,  40).    They  should  be  conveniently  situated, 


126 


HOSPITAL   ARCHITECTURE 


so  that  the  bed  may  be  wheeled  there  at  any  time.     Such  balconies  should  be  esti- 
mated of  greater  value  than  play  rooms  and  day  rooms.     Figure  41  shows  a  con- 


Fig.  39. — A  balcony. 


Fig.  40. — Reinforced  concrete  balconies  obtained  by  continuing  the  floor  slabs  over  and  beyond  the 
exterior  walls.     A  very  economic  form  of  construction  of  durable  and  fireproof  porches. 


venient  form  of  window  letting  on  to  these  balconies  from  the  ward.  The  serving- 
room,  toilet-  and  bath-room,  day  wards,  and  porches  should  be  in  direct  connection 
with  the  wards,  so  that  they  may  be  under  the  observation  of  the  ward  nurse,  and 


DIVISIONS    OF    A   GENERAL   HOSPITAL 


127 


Section- 


E  LE.VATION- 


Fig.  41.— Double  hung  windows  opening  on  balcony.  Panel  below  sill  slides  up  same  as 
sash.  Scale  detail  of  double  hunt;  window  lending  to  porch  with  a  balanced  bottom  panel  which 
can  be  easily  raised  and  leave  the  passageway  from  room  to  porch  unobstructed  for  rolling  chairs 
or  beds. 


128 


HOSPITAL    ARCHITECTURE 


for  this  the  upper  part  of  as  many  as  possible  of  the  partitions  should  be  of  glass. 
The  partitions  between  the  day  rooms  and  ward,  also  between  porches  and  ward, 
should  have  only  a  very  light  framework  of  wood  or  metal  and  as  much  glass  as 
possible. 

The  convenience  of  the  nurses  is  a  point  of  the  greatest  importance,  and  the 
building  should  be  so  planned  that  a  certain  number  of  nurses  may  care  well  for 
the  largest  number  of  sick,  observe  the  convalescents  at  play,  and  where  they  will 
be  required  to  take  the  fewest  steps. 

Metal  linen  closets  and  medicine  cases  (Fig.  42),  also  running  water,  should 
be  placed  in  each  ward,  bathing  and  toilet  facilities  nearby;  also  a  small  refrigera- 


Fig.  42. — Metal  closets  for  linen  and  medicine  cases. 


tor  and  hot  plate  in  adjacent  alcoves  or  rooms  separated  from  the  ward  by  clear 
plate-glass  partitions,  so  that  the  nurse  may  remain  in  the  ward  or  observe  the 
patients  as  much  as  possible. 

If  the  convalescent  children  can  play  on  balconies,  or  in  sun  parlors  or  play 
rooms,  good  administration  will  require  a  watcher  in  each  of  these  rooms,  or 
arrangements  that  will  enable  her  to  see  all  at  once.  A  large,  bright  ward  and  a 
good  balcony  offer  all  that  is  necessary  for  the  few  children  who  are  apt  to  be  up 
and  out  of  bed  at  one  time.     The  meals  can  be  well  arranged  for  in  the  ward  itself. 

There  should  be  in  each  department  or  on  each  floor  a  kitchen,  laboratory, 


DIVISIONS    OF    A    GK. MORAL    HOSPITAL 


129 


linen  closet,  nurses'  toilet-room,  janitor's  closet,  storeroom  for  wheel  chairs,  slop- 
sink  closets,  and  a  surgical  dressing-room  adjacent  to  the  surgical  wards.  Every 
ward  should  have  running  water,  so  that  the  attendants  may  wasti  their  hands  after 
leaving  each  patient. 

A  bath-room  adjoining  a  ward  with  a  window  between,  so  that  the  nurse  can 
bathe  one  child  and  observe  the  ward  at  the  same  time,  is  a  good  arrangement, 
probably  better  than  having  the  tub  in  a  corner  of  the  ward  or  in  an  alcove,  but  this 
is  often  done,  and  is  preferred  by  some.  A  small  room  or  alcove  arranged  for  stor- 
ing milk  and  oilier  food  for  the  night  and  warming  it  when  needed,  also  directly 
connected  with  a  ward  in  the  same  manner  as  described  for  the  bath,  is  required 
and  desirable  for  nurslings'  wards. 

Details. — Walls  in  bath,  toilet,  sink  rooms,  and  floor  pantries  or  kitchens  should 
he  tiled  aliout  o  feet  high,  and  if  the  means  permit  the  walls  of  wards,  day  rooms, 
and  balconies  should  be  tiled  about  3|  feet  high.  The  tiling  should  extend  into  the 
window  reveals  and  the  sills  should  be  of  some  impervious  material,  not  too  high, 
mi  as  to  permit  the  children  to  see  things  out  of  the  window,  but.  it  is  probably 
besl  to  slope  the  window-sills  so  that  the  children  cannot  stand  or  sit  on  them. 

Radiators  should  be  enclosed  in  boxes  of 
wire  mesh  to  protect  the  children  from  con- 
tact with  the  heated  surfaces.  No.  18  wire 
woven  into  a  square  mesh  of  five  per  2  inches 
and  galvanized  is  quite  suitable. 

Radiators  standing  against  the  walls 
should  have  hoods  to  deflect  the  air-currents 
from  the  walls;  this  tends  to  a  better  circu- 
lation and  protects  the  wall  from  becoming 
blackened. 

Double  casement  windows  and  double 
transoms  have  the  advantage  of  permitting 
the  passage  of  the  greatest  amount  of  air  and  may  serve  as  doors  to  balconies, 
and  when  double  sash  are  used  the  glass  does  not  become  obscure  by  vapor.  The 
child  should  have  a  view  out  of  doors,  and  where  the  beds  cannot  be  placed  so  that 
it  faces  the  windows  large  mirrors  are  sometimes  provided  on  the  opposite  walls  so 
that  it  may  have  some  view. 

Door-sills  are  not  necessary,  but  in  some  European  institutions  the  whole 
floor  of  the  room  toward  which  the  door  sw'ings  is  about  ^  inch  lower  than  the  floor 
of  the  adjoining  room,  so  that  the  lower  edge  of  the  door  swings  against  a  ^-inch 
brass  edge.  This  arrangement  is  also  used  where  doors  open  on  balconies.  The 
portion  where  the  hand  usually  strikes  should  be  guarded  by  glass  or  celluloid. 

For  every  bed  there  must  be  a  wall  cupboard  over  the  bed,  with  glass  door  to 
let  down  and  form  shelf.  This  is  to  take  the  place  of  individual  tables,  which  are 
costly,  unsightly,  and  in  the  way.  (See  Fig.  43.)  There  must  lie  a  small  clinical 
laboratory  on  each  floor.  There  must  be  a  linen  room  on  each  floor  and  auxiliary 
linen  closets  (preferably  metal  and  glass)  in  each  ward. 

All  medicine  cabinets  must  be  self-locking  and  located  in  the  wards — this  and 
previous  features  to  enable  nurses  to  remain  in  the  wards  and  not  have  to  go 
outside  to  get  things;  there  must  be  bath  arrangements  in  every  baby  ward  for 
the  same  reasons. 

The  dining-room  off  of  each  complete  unit  is  useful,  but  tiiis  can  be  combined 
With  the  porches,  and  il  is  belter  not  to  create  this  space  for  such  usage  except  in 
the  most  elaborate  construction. 


Fig.  43. — Wall  cabinet. 


130 


HOSPITAL    ARCHITECTURE 


There  should  be  three  operating-rooms,  one  for  clean  and  one  for  pus  cases,  and 
one  for  minor  work,  such  as  adenoids  and  tonsils,  and  this  last  very  simple  and 
easily  and  quickly  cleaned,  and  need  not  be  very  well  lighted  as  most  such  work  is 
done  under  artificial  light. 

There  should  be  a  serving-room  adjacent  to  each  complete  unit,  fitted  with  gas, 
steam  table,  etc.,  and  so  arranged  that  fluid  foods  and  children's  between-meal 
nourishment  can  be  correctly  and  expeditiously  prepared. 


Fig.  44. — Babies'  bath  cabinet. 


There  should  be  an  x-ray  and  fluoroscopic  room,  also  fitted  with  electric 
apparatus  for  treatment. 

If  the  childrens'  hospital  is  an  adjunct  of  a  larger  institution  it  should  have  a 
room  fitted  for  cooking  for  special  purposes  in  case  of  necessity  to  isolate  the  whole 
building.  Similarly  there  should  be  at  least  a  small  hand  laundry  in  the  basement, 
with  a  few  tubs  and  a  dryer. 

Spaces  should  be  provided  for  the  storage  of  wheel  chairs,  bed  elevators,  and 
rollers,  an  incubator  room  with  electrothermo  regulator  and  outside  ventilation, 
a  play  room  or  gymnasium  for  a  Zander  outfit  and  for  exercising  for  larger  children. 


DIVISIONS    OF    A    GK.NKRAL    HOSPITAL 


131 


The  ordinary  form  of  bath-tub  is  not  suitable  for  babies.  A  shallow  sink-like 
tray  on  a  pedestal,  which  does  not  require  a  nurse  to  stoop,  is  probably  the  most 
suitable;  a  combination  cock  with  hose 
and  spray  nozzle  is  better  than  a  full 
tub-bath.  Such  a  device  is  shown  in  Fig. 
44.  It  is  the  design  of  Dr.  Arthur  B. 
Ancker,  Superintendent  of  the  St.  Paul 
City  and  County  Hospital.  The  tank 
above  is  connected  with  the  hot-  and 
cold-water  supply.  The  tank  is  filled 
and  the  temperature  of  the  water  accu- 
rately measured  before  the  bathing  be- 
gins. It  is  a  delicate  matter  to  place 
the  thermometer  so  that  the  actual 
temperature  of  the  water  in  the  tank 
shall  be  taken;  a  thermometer  fixed  in  a 
tube  outside  the  tank  will  not  do,  be- 
cause the  water  then  may  be  stagnant 
and  register  either  much  lower  or  much 
higher  than  that  in  the  tank.  Rather 
the  thermometer  should  be  set  directly 
into  the  tank  at  an  angle,  and  located  as 
nearly  as  possible  to  the  point  where  the 
water  is  withdrawn  for  the  baths.  Both 
hot  and  cold  water  should  be  let  in  at 
the  same  time  and  allowed  to  stand  for 
several  minutes  before  being  used,  so 
that  it  will  be  thoroughly  mixed.  An  ex- 
cellent recording  thermometer  for  this 
purpose  is  made  by  Schaefer  and  Buden- 
berg  Manufacturing  Co.,  of  New  York 
(Fig.  45).  It  permits  of  the  reading  record 
being  placed  at  a  considerable  distance. 

A  refinement  of  the  bathing  plates  is 
now  under  construction.  It  consists  of 
a  white  metal  water  container,  2  inches 
thick  and  long  and  wide  enough  to  cover 

the  porcelain  bath  plate,  one  for  each  side  of  the  cabinet.  There  is  a  funnel-tube 
at  the  upper  and  inner  corner  out  of  the  way,  for  filling  with  warm  water  from  the 
tank.  There  are  two  metal  yokes  with  buttons  to  fasten  the  two  beds  together  so 
they  will  not  move  while  in  use.  When  not  in  use  the  beds  can  be  emptied, 
dried,  and  hung  up. 

Linen  cabinets  should  be  numerous  and  recessed  into  the  walls  or  partitions 
in  wards  and  bath-rooms  or  very  close  to  them. 

Railings  on  stairs  and  balconies  should  be  of  vertical  bars  with  no  cross-rods,  so 
that  a  child  cannot  find  a  foot-rest  for  climbing;  probably  5  feet  high  will  be  suffi- 
cient  on  balconies,  but  on  stairs  they  should  be  even  higher. 

A  large  wall  clock  with  a  lar<;e  conspicuous  second-hand  is  very  valuable,  since 
the  pulse  can  be  counted  at  any  part  of  the  room  without  contaminating  a  watch 
by  the  infected  lingers. 

A   milk  station  is  necessary,   and  should   contain   a   separator,   a   pasteurizer, 


Fig.  45. — Recording  thermometer. 


132  HOSPITAL   ARCHITECTURE 

peptonize:-,  refrigerator,  a  testing  table,  and  an  agitator.  The  power  to  drive  the 
machinery  should  be  electricity,  the  room  in  as  cool  a  location  as  possible,  convenient 
for  the  receipt  and  return  of  milk  cans,  and  also  to  the  dumb-waiters  reaching  to 
the  several  floors.  This  milk  station  is  described  in  greater  detai  under  the  sec- 
tion on  Milk  in  the  Hospital. 

A  stationary  laundry  tub  in  each  sink-room  is  very  useful. 

An  outdoor  play  ground  for  mild  weather  and  a  sunny  general  play  room,  with 
gymnastic  apparatus  or  a  Zander's  outfit  for  larger  children,  will  be  of  advantage. 

The  infants'  floor  or  department  should  have  an  incubator  room,  or  possibly 
a  more  preferable  arrangement  is  to  have  small  box-like  rooms  for  the  same  pur- 
pose, from  6  to  7  feet  square  and  7  or  8  feet  in  height,  with  constant  temperature, 
thermostats,  air  inlets,  and  outlets;  air  propelled  by  small  electric  fans  and  heated  by 
electric  heaters.  It  is  best  to  make  the  walls  of  these  rooms  of  double-plate  glass, 
set  and  puttied  into  iron  frames,  with  cork  insulation  in  floors,  ceilings,  and  walls. 

The  infants'  department  should  also  have  rooms  for  wet  nurses,  with  sleeping 
apartment  of  their  own  with  separate  bath-rooms.  Provision  should  also  be  made 
for  a  number  of  nursery  maids.  A  few  of  these  will  be  needed  to  assist  the  nurses 
in  the  wards  to  oversee  the  children  on  the  balconies  or  at  play,  or  to  take  them  out 
in  perambulators.  Nursery  maids  for  service  in  families  are  sometimes  trained 
in  childrens'  hospitals,  so  that  the  number  of  rooms  set  aside  for  their  use  must  be 
governed  accordingly.  They  should  also  have  a  separate  sleeping  apartment  with 
their  sitting-room  and  bath-room. 

The  wards  should  be  separated  into  free  wards,  semiprivate  wards  for  part- 
paid  patients,  and  also  provisions  for  private-room  cases  separated  from  the 
remainder  of  the  hospital.  There  should  also  be  quiet  rooms  for  critically  sick  chil- 
dren, so  that  their  parents  can  be  with  them. 

If  the  nurses,  doctors,  orderlies,  elevator  men,  common  house  men,  maids,  and 
wet  nurses  do  not  sleep  in  the  building  some  provision  must  be  made  to  accommo- 
date a  number  of  them  in  times  of  isolation,  so  that  some  places  must  be  so  ar- 
ranged that  they  may  be  used  for  bed-  and  dining-rooms  for  such  persons. 

Inasmuch  as  children  play  directly  on  the  floors,  it  is  highly  desirable  that 
these  be  warm  and  have  some  elasticity,  so  that  the  requirements  for  a  good  floor 
for  a  general  hospital  are  intensified  in  a  children's  hospital.  "Battleship"  linoleum 
seems  best  to  meet  all  the  requirements. 

The  painting  is  important.  It  should  be  of  a  very  good  material  which  will 
resist  scrubbing,  as  it  is  important  that  the  walls  and  woodwork  be  washed  fre- 
quently. 

The  question  of  wall  decorations  is  an  open  one,  and  many  believe  that  the  pic- 
tures please  the  decorators  and  donors  rather  than  the  children,  and  that  the 
latter  care  very  little  for  them,  but  if  they  are  provided  they  should  be  simple, 
applied  directly  on  the  plaster.  Tile  pictures  have  the  objection  of  unpleasantly 
reflecting  light.  The  monotony  of  dead-white  walls  may  be  broken  by  an  occa- 
sional strip  of  color  or  small  stenciled  ornament. 

If  possible  there  should  be  no  projecting  edges  on  the  walls;  flush  surfaces  should 
be  used  elsewhere. 

A   New   Children's   Hospital 

The  Sarah  Morris  Hospital  for  Children,  just  now  completed  under  the  direc- 
tion of  the  Michael  Reese  Hospital,  Chicago,  is  believed  by  the  author  to  contain 
the  last  word  in  childrens'  hospital  construction,  and  for  that  reason  the  author 


DIVISION'S    OF    A    UKNKUAL    HOSPITAL 


133 


believes  the  plans  of  this  hospital,  with  some  explanatory  notes,  giving  the  reasons 
for  certain  phases  of  construction,  would  be  of  interest  as  a  contemporary  piece  of 
hospital  constructive  work,  and  for  that  reason  they  are  produced  here. 

Figure  46  outlines  the  half-basement  floor,  that  has  an  areaway  on  two  sides 
of  a  width  of  5  feet,  giving  full-sized  windows  for  this  floor.  The  space  is  broken 
into  rather  large  areas  for  miscellaneous  purposes. 

We  will  begin  with  the  entrance,  by  way  of  a  tunnel  from  the  main  Michael 
Reese  Hospital  building,  and  we  first  come  upon  a  large  kitchen,  and  adjoining 
a  service-room  that  is  connected  by  the  dumb-waiter  with  the  serving-rooms  on 
the  floors  above.  This  kitchen  may  be  at  any  time  employed  for  its  legitimate 
purposes,  but  it  is  contemplated  now  to  feed  the  childrens'  hospital  from  the  main 


Fig.  46. — Sarah  Morris  Hospital,  ground  floor. 


kitchen  of  the  Michael  Reese.  This  kitchen,  serving-room,  and  the  storeroom 
adjoining  make  up  a  service  unit.  The  next  unit  is  that  devoted  In  the  residence 
of  wet  nurses.  There  are  three  of  these  rooms  that  may  be  used  for  two  we1 
nurses  each  and  two  babies,  as  the  occasion  requires,  and  there  are  bath  and  toilet 
between. 

The  next  area  on  our  way  back  to  the  point  of  beginning  is  the  milk  station, 
which  is  divided  into  three  rooms.  No.  :•>  being  the  pasteurizing  room.  No.  4  the 
work  room,  and  a  third  room,  not  marked  on  the  plans,  but  beginning  where  the 
word  "milk"  occurs,  and  taking  up  10  feet  of  space  by  the  full  width  of  the  room 
and  devoted  to  cleaning  purposes,  that  is,  the  slop-sinks,  utensil  sterilizer,  and  so 
on.     The  churn,  separator,  and  peptonize!'  are  putside  of  this  small  room    0] 


134 


HOSPITAL    ARCHITECTURE 


from  a  motor  that  turns  a  main  shaft  running  the  full  width  of  the  room.     This 
complete  milk  station  is  shown  in  the  section  on  Milk  in  the  Hospital. 

The  next  room,  No.  5  of  the  plan,  is  the  sewing  and  linen  room,  in  which  there 
are  shelves  and  cupboards  for  keeping  the  reserve  stock  of  linens  for  the  establish- 
ment. It  will  be  noted  there  are  two  dumb-waiters  connected  with  this  room: 
one  of  them  leads  only  to  the  one  floor  immediately  above,  which  we  will  see 
presently  is  the  observation  department  of  the  hospital,  and  consequently  likely 
to  contain  communicable  diseases.  A  second  dumb-waiter  leads  to  the  second, 
third,  and  fourth  floors,  and  has  no  outlet  at  the  first  floor.  It  is  thought  that  in 
this  way  the  spread  of  infections  from  the  first  floor  will  be  minimized. 


Fig.  47. — Sarah  Morris  Hospital,  first  floor. 


The  next  areas  of  importance  form  a  unit — that  is  No.  10,  a  locker  room  for 
the  childrens'  clothing;  a  soiled-clothes  room,  No.  11,  and  a  laundry,  No.  12.  It 
will  be  noted  that  the  laundry  chute,  which  we  have  treated  elsewhere,  comes 
down  between  the  laundry  and  soiled-clothes  room,  and  soiled  clothing  may  be 
dropped  from  the  floor  above,  either  into  the  laundry,  to  be  there  washed  or  disin- 
fected, or  into  the  soiled-clothes  room,  to  be  treated  in  the  mattress  sterilizer,  or 
disinfector,  as  it  is  called  in  the  plans.  The  plan  of  this  disinfector  is  such  that  one 
end  opens  into  the  soiled-clothes  room,  into  which  the  soiled  clothing  or  infected 
mattresses  or  other  material  are  put,  and  the  other  end  opens  into  a  clean  room,  or 
locker  room,  in  which  the  childrens'  lockers  are  kept.  The  small  trap  door,  indi- 
cated in  the  plans,  in  the  soiled-clothes  room  leads  only  from  the  bath-room  of  the 
admission  department,  one  floor  above. 


DIVISIONS   OF    A   GENERAL   HOSPITAL  135 

This  floor  contains  almost  all  of  the  administrative  departments  of  the  building. 

Over  on  the  corner,  No.  34,  is  a  gymnasium  or  play  room  lor  the  children, 
about  30  feet  square.  It  has  cement  floor,  high  walls,  with  skylight  ami  ventila- 
tors all  above. 

Admission  Department. — The  first  or  main  floor  of  the  building  contains  prac- 
tically three  units — an  admission  suite,  an  observation  department,  and  the  execu- 
tive department,  including  the  entrance,  offices,  and  reception  rooms. 

Beginning  with  the  vestibule,  which  is  the  entrance  of  the  admission  depart- 
ment, we  enter  the  main  waiting-room,  in  which  there  are  two  toilets  and  basin-, 
a  drinking  fountain,  and  seats  for  parents  and  children  while  waiting.  There  are 
three  examination  rooms,  Nos.  112,  114,  and  117.  It  will  be  noted  there  are  small 
dressing  closets  off  each  of  these  examination  rooms — merely  for  the  purpose  of 
saving  the  doctor's  time;  when  he  finishes  examining  a  child  it  may  be  taken  into 
one  of  these  closets  and  dressed  by  the  mother,  during  which  time  he  may  be  exam- 
ining another  child. 

When  it  is  finally  determined  that  the  child  is  acceptable,  it  is  taken  into  room 
No.  Ill,  marked  entry  bath,  which  is  fitted  with  a  high  bath-tub  in  the  center  of 
the  room  and  cabinets  containing  hospital  clothing;  there  is  also  an  opening  into 
the  laundry  chute,  and  another  into  a  clothes  chute,  so  that  the  child's  bundle  of 
clothing  may  be  dropped  into  the  soiled-clothes  room  below  to  be  disinfected  before 
being  put  away. 

It  may  be  stated  just  here  that  the  disinfector  below  stairs  contains  one  large 
horse  with  eight  bars,  and  it  is  intended  to  use  metal  clothes  pins  to  fasten  all  the 
clothing  of  one  child  to  each  bar,  that  wrould  make  it  possible  to  disinfect  the  cloth- 
ing of  eight  children  at  one  time,  and  also  to  disinfect  two  or  three  mattresses  at  the 
same  time  if  desired. 

Across  the  hall  from  the  waiting-room  are  two  isolation  rooms,  each  containing 
basin,  toilet,  and  bath.  If  it  is  determined  after  examination  that  the  applicant 
has  a  communicable  disease,  and  for  that  reason  cannot  be  accepted  as  a  patient, 
the  child  and  mother  are  placed  in  one  of  these  rooms,  and  kept  there  completely 
isolated  from  all  other  parts  of  the  hospital  until  definite  arrangements  can  be  made 
for  its  care — in  this  case  until  the  health  department  of  the  city  can  call  for  the 
child  in  its  own  ambulance.  These  rooms  contain  Terrazzo  tile  flooring  and  Keene 
cement  walls  and  ceiling  covered  with  zinc-enameled  paint,  in  order  that  they  may 
be  disinfected  with  live  steam,  if  necessary,  with  a  5  per  cent,  carbolic  spray  or 
with  formaldehyd  spray.  There  is  a  small  laboratory  room,  No.  123,  for  the 
purpose  of  examining  smears  and  doing  emergency  wrork  connected  with  the 
admission  department. 

After  the  child  has  been  accepted  and  garbed  in  hospital  clothing  it  is  taken 
along  the  passage  marked  124  and  125  over  to  the  corridor  marked  132.  which  is 
the  observation  department  of  the  institution.  Under  the  section  on  Childrens' 
Hospitals  a  photograph  is  shown  of  a  vista  down  through  the  six  observation  rooms 
of  this  department,  with  glass  partitions  between.  Each  of  these  rooms  is  fitted 
with  hot  and  cold  basin.  In  the  figures  D.  W.  are  shown  the  linen  chutes  or  dumb- 
waiters, one  opening  into  the  corridor  on  this  floor,  the  other  going  past  without 
stopping.  At  the  extreme  end  of  the  corridor,  room  No.  101,  is  a  surgical  dress- 
ing-room, intended  to  be  used  for  children  hurt  at  the  time  of  admission,  and  not 
only  dressings  but  minor  surgery  may  be  done  there.  It  is  fitted  with  enameled 
metal  cabinets  along  one  side  of  the  room,  and  on  the  other  side  are  the  sterilizers 
and  sink;  a  dressing  table  or  small  operating  table  occupies  the  middle  of  the 
floor. 


136 


HOSPITAL   ARCHITECTURE 


Across  the  hall  from  this  are  two  rooms,  Nos.  130  and  131,  marked  "Isolation." 
In  the  event  that  a  child  occupying  one  of  the  observation  rooms  develops  some- 
thing suspicious  so  as  to  make  it  necessary  to  remove  it  from  the  apartment,  and 
yet  it  is  not  desired  to  take  the  child  into  an  isolation  hospital,  it  is  placed  with 
a  nurse  in  one  of  these  isolation  rooms — the  door  off  the  corridor  is  immediately 
closed  and  may  be  sealed.  The  first  small  room,  as  we  enter  from  the  corridor, 
is  a  service-room,  containing  sink  and  drain  board,  with  hot  and  cold  water,  a  gas 
plate,  and  small  refrigerator;  in  the  other  small  room  are  bath,  basin,  and  toilet  for 
the  nurse,  since  a  child  in  such  a  situation  will  be  bathed  and  served  in  bed.  The 
outside  openings  to  these  two  suites  are  porches,  each  enclosed  with  high  wire  fence, 
and  the  gates  are  provided  with  locks.  It  is  through  this  outside  entrance  that 
food  and  necessaries  of  all  sorts  are  brought  to  the  compartment  by  the  orderly, 
and  set  upon  the  porch  where  the  nurse  may  get  them. 


Fig.  48. — Sarah  Morris  Hospital,  second  floor. 

The  serving-room  for  this  floor,  marked  No.  128,  connects  with  a  dumb-waiter 
from  below,  and  contains  a  refrigerator,  steam  table,  gas  plate,  and  plenty  of  tray 
racks.  The  next  room,  No.  129,  is  the  slop-sink  room  for  the  department,  and  con- 
tains a  metal  cabinet  7  feet  high  and  7  feet  wide  as  a  receptacle  for  bed-pans  and 
urinals,  and  in  which  to  lock  enema  cans,  hot-water  bottles,  ice-caps,  rubber  tubing 
of  various  sorts,  and  the  general  supplies  of  that  character.  This  room  also  con- 
tains a  slop  sink,  the  utensil  sterilizer,  and  will  contain  a  typhoid  stool  sterilizer 
as  soon  as  a  proper  one  can  be  found  or  designed. 

The  Second  Floor. — This  floor  has  three  hospital  units  and  certain  administra- 
tive areas,  as  shown  in  the  plans.  It  will  be  necessary  only  to  call  attention  to  the 
arrangement  of  the  wards  and  the  auxiliary  rooms.      One  of  these  large  wards  at 


DIVISIONS    OF    A    GKNKRAL    HOSPITAL 


137 


the  end  of  the  building  is  for  male  children,  older  than  the  infant  age,  and  the 
other  for  females.  There  is  a  quiet  room  off  each  one,  in  which  a  specially  sick 
child,  or  one  who  is  nervous,  or  a  child  who  is  dying,  may  be  placed.  In  the  sec- 
tion on  Childrens'  Hospitals  the  sun  porch  and  the  things  relating  to  them  are 
shown  in  photograph  form. 

The  furnishing  of  the  ward  is  extremely  simple — a  bed,  and  over  the  head  of 
each  lied  a  small  ward  cabinet,  a  drawing  of  which  is  also  shown  under  the  section 
on  Childrens'  Hospitals. 

Attention  is  called  again  to  the  laundry  chute,  w:hich  opens  on  this  floor  into 
the  corridor,  so  that  the  soiled  clothes  from  the  whole  floor  may  be  placed  in  it  at 
a  pretty  nearly  central  point. 


Fig.  49. — Sarah  Moms  Hospital,  third  floor. 

It  will  be  noted  that  there  are  two  dressing-rooms  on  this  floor,  rooms  Nos.  204 
and  205 — one  for  the  treatment  of  diseases  of  the  ear,  nose,  and  throat,  and  the 
other  for  miscellaneous  surgical  dressings. 

Infants'  Floor.— The  third  floor  contains  three  complete  units  for  infants. 
These  ward  units  are  practically  the  same — a  sun  porch  and  two  wards,  separated 
by  the  bath.  The  bath  for  this  latter  is  given  in  detail  elsewhere.  The  room 
otherwise  contains  a  refrigerator,  gas  plate,  and  a  cabinet  fur  such  clothing  as 
diapers,  and  which  is  furnished  with  a  small  steam  coil  at  the  bottom,  which  may 
be  turned  on  when  necessary  to  keep  the  children's  clothing  warm. 

There  are  two  small  rooms  on  this  floor  which  will  deserve  an  instant's  atten- 
tion, "Box"  No.  1  and  "Box"  No.  '_'.  These  are  merely  small  rooms  in  which 
to  keep  children  that  ought  not  to  be  placed  in  the  ward  or  with  other  children. 


138 


HOSPITAL    ARCHITECTURE 


Another  room  which  deserves  attention  is  the  couveuse,  or  incubator  room. 
This  room  is  16|  feet  long  by  10  feet  wide,  with  a  plate-glass  partition  cutting  off 
a  vestibule  6  by  10,  in  which  the  nurse  may  stay  out  of  the  greater  heat  of  the  incu- 
bator room  proper.  The  incubator  room  itself  is  a  cube  10  feet  each  way,  lined 
with  cork,  felt,  and  asbestos,  besides  the  other  normal  coverings.  There  is  a 
double  window,  with  separate  double  transom,  and  exhaust  fan  and  an  intake 
fan.  It  is  necessary,  in  connection  with  the  incubation  of  premature  infants,  to 
have  not  only  the  proper  temperature,  but  the  proper  humidity  and  the  proper 
ventilation,  and  these  things  must  be  carefully  considered  before  such  a  room  can 
be  considered  better  than  the  now  almost  obsolete  baby  incubators  that  are  24  by 
18  by  12  inches  in  size. 


Fig.  50. — Sarah  Morris  Hospital,  fourth  floor. 


The  Private  and  Operating-room  Units. — The  fourth  floor  has  two  complete 
units — one  made  up  of  a  series  of  private  rooms,  and  the  other  the  operating 
department.  Each  of  the  private  rooms  has  a  sun  porch,  or  small  balcony,  open- 
ing off  the  window,  which  is  the  outer  opening,  double-casement  style.  Each 
private  room  has  its  own  toilet  and  basin,  and  there  is  a  bath  between  each  pair  of 
rooms,  with  double  doors,  so  that  the  bath  may  be  used  either  in  common  for  the 
two  rooms  or  by  either  one  exclusively. 

The  operating  suite  contains  a  surgeon's  dressing-room,  No.  416;  a  nurse's  work 
room,  No.  417;  an  anesthetizing  room,  No.  420,  at  the  end  of  the  corridor;  a  ster- 
ilizer room,  and  a  general  utility  or  janitor's  room. 

There  are  three  operating  rooms — two  facing  to  the  north — one  for  clean  and 


DIVISIONS    OF    A    GENERAL    HOSPITAL  139 

the  other  for  pus  cases,  and  a  nose  and  throat  operating-room  facing  to  the  south, 
and  not  very  well  lighted,  because  most  of  the  work  done  in  this  room  is  done  under 
artificial  light. 

It  will  be  noted  that  this  suite  is  entirely  cut  off  from  the  rest  of  the  hospital, 
except  by  way  of  the  elevator  and  double  doors  at  the  end  of  the  corridor,  leading 
to  the  common  stairway,  and  these  may  be  locked  if  occasion  requires.  The 
elevator  has  a  special  opening  for  this  department. 

Attention  may  be  called  to  the  stair  hall  in  this,  as  well  as  the  other  floors,  be- 
cause the  landings  are  to  be  used  for  sort  of  reception  rooms.  The  floors  in  these 
stair  halls  are  made  of  art  marble,  in  figures;  there  is  a  telephone  in  each,  and 
they  are  to  be  furnished  as  reception  and  waiting  rooms. 

Reverting  to  the  operating  department  for  a  moment,  it  will  be  seen  there  are 
two  spaces  in  the  corridor  for  wall  cabinets.  These  are  instrument  cabinets,  and, 
like  all  the  cabinets,  closets,  and  receptacles  throughout  the  building,  they  are  made 
of  metal  set  into  the  partition  flush  with  the  wall. 

General  Arrangement. — All  the  corridors,  and  all  wards  and  private  rooms,  have 
a  floor,  covering  of  "  battleship  "  linoleum,  j-inch  thick,  and  set  flush  with  the  floor 
edge  of  the  base  cove  everywhere,  and  this  base  cove  reaches  out  on  to  the  floor  for 
a  distance  of  6  inches  from  the  vertical  wall. 

The  administration  rooms  have  a  floor  covering  of  hexagonal  terrazzo  flags, 
12  inches  in  diameter;  the  corridors  and  all  parts  of  the  operating  suite  have  a  floor 
covering  of  white  vitrified  tile  G  inches  in  diameter. 

The  wall  coverings  of  the  building  are  as  follows: 

All  corridors,  stairways,  and  the  rooms  in  basement,  excepting  the  milk  station 
and  service  rooms,  are  of  light  buff  or  deep  cream  color,  with  ceiling  and  9-inch 
frieze  of  a  still  lighter  color. 

The  first,  or  main  floor,  which  is  naturally  not  so  light  as  the  upper  floors,  is 
painted  in  a  light  steel  gray,  with  2-inch  stencil  of  a  darker  color,  10  inches  from 
the  ceiling;  ceiling  and  10-inch  frieze  being  a  grayish  white. 

The  second  floor  is  tinted  sea  green,  with  ceiling  and  frieze  of  a  much  lighter 
tint,  and  2-inch  stencil  between  of  a  darker  green. 

The  infants',  or  third  floor,  is  in  baby  blue,  with  ceiling  and  frieze  of  a  lighter 
color. 

The  private  rooms  on  the  fourth  floor  are  painted  in  pairs,  but  the  colors  being 
those  that  prevail  on  the  floors. 

The  operating  suite  throughout,  as  well  as  all  bath-rooms,  slop-sink  rooms,  and 
serving-rooms,  are  all  in  zinc-white  enamel  paint. 

The  general  construction  of  the  building  is  a  light-gray  brick,  with  granite  and 
terra-cotta  facings,  reinforced  concrete  foundations  and  floors,  mackolite  partitions. 
The  window  frames  are  of  wood,  and  all  door  frames  and  glass-partition  frames  are 
of  steel. 

MATERNITY  HOSPITAL 

The  arrangements  and  details  of  a  maternity  hospital  and  its  equipment  should 
not  differ  from  those  of  a  general  hospital,  excepting  that  the  finish  of  the  wards  and 
private  rooms  may  have  slightly  more  grace  in  the  matter  of  form  and  decoration 
and  less  severity. 

A  parlor  on  every  floor,  open  loggias,  porches,  and  sun  parlors  are  very  desir- 
able.    The  special  designations  are  as  follows: 

Waiting  wards  and  rooms. 

Examination,  preparation,  labor,  birth,  and  rest  rooms. 


140  HOSPITAL    ARCHITECTURE 

Comfortably  furnished  rooms  for  the  doctor  and  nurse,  also  for  the  husband 
or  mother  of  the  patient. 

Pleasant  nurseries,  with  one  or  more  infants'  baths. 

Incubator  room,  such  as  described  in  the  Childrens'  Hospital,  also  wet-nurses' 
rooms. 

It  is  only  before  and  during  labor  that  the  patient  needs  much  nursing.  If 
she  has  entered  the  hospital  before  labor,  it  is  because  she  is  sick  with  some  compli- 
cation of  pregnancy,  and  she  will  need  attention.  During  labor  every  facility  for 
aseptic  surgery  will  be  required,  but  afterward  she  is  a  well  woman,  just  passed 
through  a  period  of  suffering,  and  before  that  a  long  siege  of  anxiety  and  nervous 
tension.  Therefore,  she  needs  cheerful  surroundings,  flowers,  sunshine,  bright 
colors,  and  the  company  of  at  least  a  few  intimate  friends  to  share  her  pleasure  at 
the  happy  advent  of  the  little  stranger. 

ARCHITECTURE  OF  THE  SMALL  HOSPITAL 

The  principles  of  hospital  architecture  apply  equally  in  the  small  and  the 
large  institution.  The  radical  difference  between  the  two  is  simply  that  one  con- 
tains a  very  few  units  and  the  other  a  great  number  of  units.  In  the  large  hos- 
pital there  are  questions  of  transportation  of  food  and  hospital  supplies  that  do 
not  apply  in  the  small  institution.  There  are  questions  of  light,  and  perhaps 
problems  of  ventilation  and  heating,  that  render  the  scheme  of  architecture  more 
complicated.  We  have  taken  up  these  questions  of  light,  ventilation,  transporta- 
tion of  supplies,  and  other  economies  of  administration  as  they  apply  in  any  insti- 
tution, and  it  will  not  be  difficult  for  us  to  apply  them,  no  matter  what  the  size 
or  the  purpose  or  the  location,  and  about  the  only  thing  that  we  need  consider 
here  is  the  economy  of  arrangement  for  small  units,  and  a  small  number  of  each, 
considering  the  fact  that  oftentimes  we  will  have  to  use  a  single  unit  for  a  greater 
number  of  purposes.  For  instance,  a  small  hospital  of,  say,  four  units,  may  have 
to  care  for  all  the  specialties  in  medicine  and  surgery,  and  facilities  will  have  to 
be  furnished  for  treatment  of  all  sorts  of  cases,  whereas  in  the  hospital  of  great 
size  a  single  unit  can  be  used  for  a  single  purpose,  which  greatly  simplifies  the 
architecture. 

The  hospital  unit,  as  such,  has  not  changed  greatly  in  the  past  few  years,  in 
fact,  Florence  Nightingale,  in  her  "Hospital  Construction,"  published  in  1863, 
giA^es  us  some  hospital  units  that  were  proper  for  her  day.  Figure  4  is  produced 
here  from  Florence  Nightingale's  book,  merely  as  an  indication  that  we  have  not 
progressed  very  far  in  hospital  arrangement,  notwithstanding  the  fact  that  the 
whole  science  of  medicine  has  undergone  vast  changes. 

As  against  these  old-time  plans,  we  are  producing  also  plans  for  small  hospitals 
that  have  been  recently  perfected  and  executed.  It  will  readily  be  seen  that  in 
these  plans  for  small  hospitals  the  proportion  of  space  for  administrative  pur- 
poses must  be  largely  increased,  as  compared  with  bed  space  for  patients,  and  if 
we  consider  administrative  economies,  bed  for  bed,  the  small  hospital  does  not 
compare  favorably  with  the  large  one,  and  yet  we  know  quite  well  that  a  small 
hospital  can  be  administered  more  economically,  in  point  of  help  per  patient, 
than  the  large  institution.  No  doubt  this  is  very  largely  due  to  the  fact  that  we 
must  have  greater  hall  space;  distances  are  greater,  more  walking  to  and  fro  is  to 
be  done.  But  more  important  still  is  the  fact  that  in  the  large  hospitals  more  work 
is  done  per  patient,  scientific  apparatus  is  employed,  arrangements  for  feeding 
patients  are  more  elaborate,  and  what  would  seem  abundantly  up  to  date,  and 


LRCH1  n:<Ti  RE    01    THE   SMALL   HOSPn  VL 


111 


amply  sufficient  in  the  way  of  scientific  care  of  patients  in  +  lie  small  hospital, 
would  hardly  be  considered  up-to-date  practice  in  the  large  institution. 


142  HOSPITAL    ARCHITECTURE 

The  following  plans  carry  some  illuminating  figures  and  facts  concerning  con- 
struction, especially  of  small  hospitals. 

Plan  No.  I  (Figs.  52-55) 

The  dimensions  of  this  building  are  36  feet  wide  by  79  feet  long.     The  beds 
are  placed  as  follows: 

First  floor:      2  five-bed  wards 10 

Second  floor:  5  one-bed  wards 5 

Third  floor:     6  nurses  and  two  housemaids 8 

Total  number  of  beds 23 

The  legend  which  accompanies  the  plan  explains  the  uses  of  the  various  rooms. 
The  following  is  a  synopsis  of  the  specifications: 

Concrete  foundations,  vitrified  brick  exterior,  Bedford  stone  trimmings,  terra- 
cotta flue  linings,  steel  interior  floor  supports,  yellow  pine  floor  joist,  rafters,  and 


Fig.  52. — Basement  plan:  1,  Kitchen;  2,  serving  room;  3,  refrigerator;  4,  corridor;  5,  kitchen 
storage;  6,  helps'  dining  room;  7,  nurses'  dining  room;  8,  drug  room;  9,  storage  for  drugs;  10, 
laundry;  11,  coal  room;  12,  boiler  room;  13,  helps'  toilet;  14,  morgue. 

studding;  metal  lath  on  basement  ceiling,  elevator  shaft,  and  in  dumb-waiter  shaft; 
wood  lathing  for  the  remainder;  hard  plaster  throughout,  coves  of  3-inch  radius 
in  all  plastered  angles,  steel  corner  plates  on  salient  angles;  galvanized  iron  gutters 
and  other  sheet  metal  work,  shingle  roof,  wood  columns,  and  wood  floors  for  ex- 
terior porches,  steel  frame  and  sash  for  operating-room  window,  iron  guards  for 


AKCIHTK<TUU<:    OK    THK    SMALL    HOSPITAL 


143 


basement  windows;  second  and  third  floors  deadened  with  Florian  paper,  1|  inch 
wood  strips,  the  space  between  same  filled  with  mineral  wool  and  covered  with 
hard  paper.  The  floor  surfaces  of  the  vestibule,  operating-room  and  toilet  rooms, 
magnesia  cement ;  all  other  floors  in  first,  second,  and  third  floors,  first  clear  white 
hard  maple.  The  whole  of  the  basement  floor  finished  Portland  cement.  Stair 
treads  white  maple,  trim  of  the  halls  and  corridors  in  all  stories,  the  whole  of  the 
basement  and  attic,  birch  for  natural  finish.  The  remainder  of  the  building 
birch  for  white  enamel  finish. 

The  doors,  lj  inches  thick,  flush  or  slab  doors.  The  operating,  sterilizing, 
toilet,  and  bath-room  walls  and  ceilings  enameled  with  three  coats  of  hospital 
enamel  paint. 


Fig.  53. — First  floor  plan:   1,  Vestibule;  2,  office;  3,  parlor;  4,  corridor;  5,  linen  room;  6,  floor 
pantry;  7,  bath;  S,  ward;  9,  utility  or  sink  closet;  10,  porches. 


Floors  shellacked  one  coat  and  varnished  two  coats. 

All  plaster  surfaces  not  specified  to  be  enameled,  a  coat  of  hard  oil  size  and 
three  coats  of  oil  paint,  starched  and  stippled. 

The  glass  of  operating-room  window  and  of  main  entrance  polished  plate  glass. 
The  glass  of  bath,  toilet,  morgue,  and  laundry  windows  Florentine  or  Maze 
pattern  glass.     All  other  glass  double  strength. 

Drains  and  plumbing,  according  to  the  best  and  most  modern  practice;  2-inch 
water-supply  pipe,  water  heater,  and  hot-water  storage  tank,  9  water  closets, 
10  lavatories,  5  sinks,  1  three-part  laundry  tray,  7  bath-tubs,  3  slop  sinks,  1 
operating-room  sink.  The  operating-room  sink  to  be  of  porcelain,  laundry  trays, 
kitchen  sink,  and  drug-room  sink  of  soapstone,  closets  of  vitreous  china,  all  other 
fixtures  enameled  iron. 

The  specifications  for  plumbing  include  glass  shelves,  paper  holders,  towel 
racks,  soap  dishes,  clothing  hooks  at  the  fixtures  where  such  fittings  are  required. 


144 


HOSPITAL    ARCHITECTURE 


The  specifications  describe  a  low-pressure  steam  heating  apparatus,  cast- 
iron  sectional  boiler,  cast-iron  radiators,  and  the  covering  of  all  mains  and  con- 
nections in  the  basement. 


—  Second     floor     plan  — 

**tt1fi,.,T.i.|'f.  ~-+X 

Fig.  54. — Second  floor  plan :  1,  Operating  room;  2,  sterilizing  room;  3,  operating  department 
corridor;  4,  corridor;  5,  linen  closet;  6,  floor  pantry;  7,  bath;  S,  wards;  9,  utility  and  sink  closet; 
10,  porches. 


—  Attic     Plan  — 

Fig.  55. — Attic  plan:  1,  Bedrooms;  2,  linen  and  sewing  room;  3,  upper  part  of  operating  room;  4, 
corridor;  5,  stair  hall;  6,  toilet;  7,  bath. 


Electric  wiring  in  steel  conduit  throughout  the  building. 

Insect  screens,  lighting  fixtures,  hardware,  and  tile  work  are  included. 


ARCHITECTURE   OF  THE   SMALL  HOSPITAL 


115 


1.  Nurses'   or  female  help 

bedrooms. 

2.  Storage  room. 

3.  Linen  closet. 

4.  Elevator  shaft. 

5.  Bath  and  toilet  rooms. 


1.  Private  room. 

2.  Utility  closet. 

3.  Medicine  closet. 

4.  Linen  closet. 

.5.  Duty    room    or    floor 
pantry. 

6.  Elevator. 

7.  Operating-room. 

8.  Sterilizing  room. 

9.  Surgeons'     preparation 

room. 

10.  Antispaee  to  elevator. 

11.  Public  bath  and  toilet- 

rooms. 

12.  Private  bath  and  toilet 

rooms. 

13.  Corridor. 


>  TC.      p  u  A.  » 


1.  Wards. 

2.  Office. 

3.  Parlor. 

4.  Interns'  room. 

5.  Linen  closet. 

6.  Elevator. 

7.  Men's  department   cor- 

ridor. 
S.  Duty    room     or    floor 

pantry. 
9.  Utility  i-loset. 

10.  Women's     department 

corridor. 

11.  Vault. 

12.  Public  bath  and  toilet 

room. 


• OAStMfNT  v 


1.  Kitchen. 

2.  Pantry. 

3.  Helps'  dining  room. 

4.  Nurses'  dining  room. 

5.  Laundry. 

6.  Engineer. 

7.  Boiler  room. 
s.  Coal  room. 
9.  Drug  room. 

id.  Morgue. 

11.  Storage. 

12.  Sewing. 

13.  Refrigerators. 

14.  Ambulance  entrance. 

15.  Basement  corridor. 
lii.  Elevator  antispaee. 
17.  Elevator. 


Fig.  56. 


146 


HOSPITAL    ARCHITECTURE 


The  lowest  proposals  amounted  to  26  cents  per  cubic  foot,  or  $26,260,  divided 
as  follows: 

General  work:  viz.,  walls,  floors,  roofs,  plastering,  woodwork,  painting, 

and  glass 19.25  cents. 

Plumbing 3.  " 

Heating 1.30     " 

Wiring 75      " 

Other  Items ■      1.70     " 

•    Total 26      cents. 

Plan   No.  II  (Fig.  56) 

The  width  of  this  building  is  33  feet,  the  length  111  feet,  and  contains  the 
following  beds: 

First  floor :      4  three-bed  wards 12 

1  two-bed  ward 2 

Interns 2 

Second  floor :  8  one-bed  wards 8 

Third  floor :     Nurses  and  help 12 

Basement :       Fireman 1^ 

Total  number  of  beds 37 

Each  of  two  first-floor  wards  will  accommodate  an  additional  bed,  making  a 
total  of  39  beds. 

The  cost  of  this  building,  if  erected  according  to  the  same  specifications  as 
building  No.  I,  should  not  exceed  $38,500.  The  addition  of  the  elevator  increases 
the  cubic-foot  cost  above  that  of  plan  No.  I.  If  the  three  floors  and  all  partitions 
are  built  of  fireproof  construction,  and  slate  roof  on  wood  roof  construction,  the 
cost  should  not  exceed  $45,000,  or  about  33|  cents  per  cubic  foot. 

Plan  No.  Ill  (Figs.  57-60) 

This  plan  differs  from  plans  Nos.  I  and  II  by  having  the  operating  department 
on  the  first  floor;  the  number  of  beds  are  as  follows: 

First  floor:       Superintendent 1 

Second  floor:  2  eight-bed  wards 16 

2  private  wards 2 

Third  floor :     Either  patients,  nurses,  or  help 18 

Basement :       Janitor 1 

Total  number  of  beds 38 


1.  Helps'  rooms. 

2.  Nurses'     or     patients' 

rooms. 

3.  Nurses'     or     patients' 

toilet  and  bath. 

4.  Corridor. 

5.  Elevators. 

6.  Helps'  bath-room. 

7.  Helps'  toilet-room. 


Fig.  .57— Plan  III— Third  floor  plan. 


AECHITECTOEE   OF   THE   SMALL  HOSPITAL 


147 


Fig.  58. — Plan  III — Second  floor  plan. 


1.  Private  room. 

2.  Private  room. 

3.  Ward. 

4.  Corridor. 

5.  Elevator. 

6.  Toilet-room. 

7.  Bath-room. 
S.  Bath-room. 
9.  Toilet. 

10.  Nurses'  toilet-room. 

11.  Utility  or  sink-room. 

12.  Sewing  room. 

13.  Ward. 

14.  Airing  loggia. 

15.  Dumb-waiter. 

16.  Porches. 


1.  Vestibule. 

2.  Office. 

3.  Waiting  room. 

4.  Corridor. 

5.  Elevator. 

6.  6,  6.  Private  rooms. 

7.  Toilet  and  bath. 

8.  Private  bath. 

9.  Utility  or  sink  room. 

10.  Stairs  to  basement. 

11.  Operating  corridor. 

12.  Operating-room. 

13.  Sewing  room. 

14.  Sterilizing  room. 

15.  Anesthetizing  room. 

16.  Porches. 


Fig.  59.— Plan  III— First  floor  plan. 


1. 

Kitchen. 

2. 

Sewing  room. 

3. 

Morgue. 

4. 

Corridor. 

5. 

Elevator. 

6. 

Area     and     basement 

entrance. 

7. 

Nurses'  dining  room. 

8. 

Helps'  dining  room. 

9. 

Storeroom. 

10. 

Man's  room. 

11. 

Laundry. 

12. 

Coal  vault. 

13. 

Furnace  room. 

1  1 

Storeroom. 

15. 

Ash-bin. 

Fig.  60.— Plan  III— Basement  plan. 


The  ground  dimensions  are  45  by  95  feet,  and,  if  buill  according  to  the  speci- 
fication outlined  for  Plan  No.  1,  its  cost  should  not  exceed  146,000,  and,  with 
floors  of  fireproof  construction,  fireproof  partitions,  wood  construction  roof,  and 
slate  covering,  $52,000. 


148 


HOSPITAL   ARCHITECTURE 


Plan  No.  IV  (Figs.  61-64) 

The  length  of  this  building  is  130  by  41  feet  wide,  and  contains  the  follow- 
ing beds: 


First  floor: 

Second  floor: 
Third  floor: 


Janitor  and  fireman 2 

1  ward 7 

Wards  for  1  bed 3 

Superintendent  and  interns 3 

1  ward 7 

Wards  for  1  bed 8 

1  ward 7 

Wards  for  1  bed 5 

Total  number  of  beds 42 


Fig.  61. — Basement  plan:  2,  Corridor;  3,  elevator  hall;  4,  elevator;  17,  stair  hall;  IS,  serving- 
room;  27,  kitchen  coal;  28,  kitchen  stores;  29,  kitchen;  30,  refrigerators;  31,  kitchen  stores;  32, 
helps'  dining-room;  33,  nurses'  dining-room;  34,  janitor  and  fireman;  35,  janitor  and  fireman's 
bath-room;  36,  helps'  toilet-room;  37,  laundry;  38,  coal  storage;  39,  boiler  room;  40,  ward;  41, 
diet  kitchen. 


wm  n 


£„,r,,Mh,.,r„.,r 


Fig.  62. — First  floor  plan:  1,  Vestibule;  2,  corridor;  3,  elevator  hall;  4,  elevator;  5,  office;  6, 
telephone  booth;  7,  vault;  8,  broom  closet;  9,  private  wards;  10,  private  toilet-rooms;  11,  private 
bath-room;  13,  interns;  14,  superintendent;  15,  superintendent's  bath;  16,  interns'  and  public 
bath-room;  17,  stair  hall;  18,  floor  pantry;  19,  utility  and  sink  room;  20,  general  bath-room]  21, 
water-closets;  22,  ward;  23,  quiet  room;  24,  reception  room;  25,  26,  porches;  27,  linen  cabinet; 
2S,  medicine  cabinet. 


AKCHITECTUKE    OF   THE    SMALL   HOSPITAL 


149 


Fig.  63. — Second  floor  plan:  2,  Corridor;  3,  elevator  hall;  4,  elevator;  8,  broom  closet;  9, 
private  wards;  10,  private  toilet-rooms;  11,  private  bath-room;  17,  stair  hall;  IS,  floor  pantry! 


19,  utility  and  sink  room;  20,  general  bath-room;  21,  water-closet;  22,  ward;  25,  26,  porches; 
27,  linen  cabinet ;  2S,  medicine  cabinet. 


0 

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Fig.  64. — Third  floor  plan:  2,  Corridor;  3,  elevator  hall;  4,  elevator;  S,  broom  closet;  9, 
private  wards;  IS,  floor  pantry;  19,  utility  and  sink  room;  20,  general  bath-room;  21,  water-closet; 
22,  ward;  25,  26,  porches;  27,  linen  cabinet;  2S,  medicine  cabinet;  29,  operating-room  stores; 
30,  anesthetizing  room;  31,  sterilizing-room ;  32,  operating-room;  33,  surgeons'  scrub  room;  34, 
general  toilet  and  bath-room;  35,  doctors'  toilet-room;  36,  operating  department  corridor. 

This  plan  is  designed  as  a  three-story  building  with  a  flat  roof,  and  will  cost 
approximately  855,000  if  built  according  to  the  specification  outlined  for  Plan 
No.  I,  and  $63,500  if  the  floor,  roof,  and  partitions  are  made  of  fireproof  con- 
struction. 

Plan  No.  V  (Figs.  65-69) 

This  plan  illustrates  a  building  in  the  course  of  construction  in  1012,  in  a  city 
of  about  40,000  inhabitants,  on  a  thirty-acre  tract  of  ground,  rolling,  partly  wooded, 
and  which  rises  gently  from  the  principal  approach  to  the  main  entrance,  and  falls 
away  toward  the  rear  about  the  full  height  of  the  basement,  so  that  the  kitchen 
floor  and  ambulance  entrance,  both  in  the  rear  of  the  basement,  are  level  with  the 
ground  on  their  side  of  the  building,  and  the  main  entrance  only  two  steps  above 
the  driveway  grade  at  the  front. 

Eventually,  the  nurses  are  to  be  housed  in  a  separate  building,  and  the  super- 
intendent will  be  provided  with  a  dwelling-house,  both  situated  on  the  hospital 
grounds;  temporarily,  they  will  be  accommodated  within  the  building,  but  later 
some  of  these  accommodations  will  be  altered  for  the  use  of  patients. 

The  building  is  designed  to  have  masonry  walls  with  stone  and    terra-cotta 


150 


HOSPITAL    ARCHITECTURE 


trimmings,  floors,  partitions,  and  roof  of  fireproof  construction,  copper  sheet  metal 
work  and  slate  roof.  The  floors  throughout  will  be  of  marble,  vitrified  tile,  cera- 
mic mosaic  and  Portland  cement,  the  latter  for  "battleship"  linoleum  above  the 
basement. 

The  woodwork  will  be  of  hard  wood,  finished  in  natural  finish  in  the  service 
portion  and  for  white  enamel  in  the  wards,  private  rooms,  and  operating  depart- 
ment. The  cost  stated  below  includes  all  of  the  general  work,  such  as  mason 
work,  steel,  fireproofing,  finished  cement,  ornamental  iron,  cut  stone,  terra  cotta, 
sheet  metal,  slating,  composition  roofing,  plastering,  carpenter  work  and  cabinets, 
cases,  painting,  decorations  of  walls,  glass,  marble,  terrazzo,  tile,  ceramic  mosaic 
floors,  weather  strips,  screens,  and  hardware,  as  well  as  two  boilers,  steam  heating, 
ventilating  equipment,  quartz  water  filters,  electric  passenger  elevator,  vacuum- 
cleaning  machine,  vacuum-steam  circulatory  system,  plumbing,  gasfitting,  garb- 


Fig.  65. — General  view  of  building  and  grounds. 

age  destructor,  ash  elevator,  electric  wiring,  signalling  systems,  telephone  sys- 
tem, lighting  fixtures,  laundry  machinery,  blanket  warmer,  mattress  disinfector, 
fire  hose,  refrigerators,  and  sterilizing  equipment. 

The  main  entrance,  lobby,  waiting-room,  and  office  will  have  imported  marble 
floors;  architectural  treatment  of  walls  and  enriched  ceilings. 

Toilet,  bath,  sink,  service-rooms  on  each  floor,  and  the  whole  of  the  kitchen 
department  will  have  shop-made  terrazzo  tile  floors  and  9-inch  high  shop-made 
polished  terrazzo  door  trim  plinths,  base  boards  and  coves  set  flush  with  the  plaster. 

The  whole  of  the  operating  department  and  the  dressing-rooms  will  have 
6  by  6  inch  white  flint  tile  floors  and  9-inch  terrazzo  bases  and  door  trim  plinths. 

Wards,  corridors,  and  all  other  bedrooms,  similar  plinths  and  baseboards, 
Portland  cement  floors,  which  are  to  be  covered  with  "battleship"  linoleum 
cemented  solidly  to  the  cement. 


ARCHITECTURE   OF   THE   SMALL    HOSPITAL 


151 


^ 


The  central  portion  with  the  two  sun-porch  wings,  the  power  and  laundry 
building,  were  placed  under  contract  for  $165,000.  They  contain  515,000  cubic 
feet,  at  an  average  price  of  32  cents  per  cubic  foot,  which  includes  completing  the 
building  ready  for  use,  with  the  exception  of  portable  furniture,  linoleum  tioor 


152 


HOSPITAL   ARCHITECTURE 


covering,   house  furnishings,  instruments,  driveways,  and  improvement  of  the 
grounds. 

Temporarily,  the  sun  porches  will  be  used  as  10-bed  wards,  and  the  contract 
sum  includes  bath  and  toilet  rooms,  also  emergency  stairways  in  brick  towers  at 
each  end  of  the  two  sun  porches;  these  sun  porches  are  also  of  fireproof  construction. 


AlirillTKCTlKK    OF    TIIK    SMALL    HOSPITAL 


153 


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6    A 


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Rfl.tfAP^iB^flOTPPl 


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154 


HOSPITAL   ARCHITECTURE 


ARCHITECTURE   OF   THE   SMALL  HOSPITAL  155 

The  beds  in  the  portion  under  contract  are  disposed  as  follows: 

First  floor:       Interns 2 

6  one-bed  wards 6 

2  ten-bed  wards 20 

Second  floor:  2  two-bed  wards 4 

15  one-bed  wards 15 

2  ten-bed  wards 20 

Third  floor:     10  two-bed  wards 20 

Fourth  floor:  Dormitories 10 

Total  number  of  beds 97 

The  two-story  cross-shaped  wings  which  are  to  be  erected  in  the  future  will 
increase  the  capacity  by  108,  or  a  total  of  205  beds. 

The  two  cross-shaped  buildings  will  require  no  additional  machinery  and  spe- 
cial equipment,  so  that  their  cubic-foot  cost  will  not  exceed  26J  cents,  which  will 
reduce  the  average  cost  of  the  completed  building  to  29  cents  per  cubic  foot. 

THE  COST  PER  CUBIC  FOOT  OF  SOME  OF  THE  PARTS 

The  cost  of  plumbing  per  cubic  foot  of  a  hospital  building,  where  enameled 
iron  fixtures  are  used,  in  a  large  institution  will  average  2\  cents;  in  a  small  one, 
3  cents.  In  large  institutions,  3  cents  will  be  sufficient  for  porcelain  and  vitreous 
china  fixtures. 

These  costs  are  governed  by  the  quantities,  so  that  the  cubic-foot  cost  of 
plumbing  in  one  hospital  built  by  the  writer  has  been  as  high  as  5  cents. 

Low  pressure  vacuum  steam-heating  system,  including  steam  for  laundry, 
cooking,  and  sterilizing,  also  high  pressure  boilers,  have  not  fluctuated  much 
above  or  below  2\  cents. 

The  many  other  items  required  to  build  and  complete  a  hospital  vary  so  great  ly 
in  quantity,  quality,  or  sendee  requirements,  especially  in  the  case  of  mechanical 
devices,  that  the  cubic-foot  cost  is  seldom  the  same  in  two  buildings,  and  very 
misleading  in  estimating  the  cost  of  a  proposed  building. 

The  total  cubic-foot  cost  of  the  described  building  is  as  follows: 

Masonry. 

Reinforced  concrete — structural  tile  work. 

Plain  cement. 

Steel  and  iron  work. 

Ornamental  and  light  iron  work. 

Cut  stone. 

Terra  cotta. 

Fireproofing. 

Sheet  metal  work  and  slating. 

Composition  roofing. 

Plastering. 

Carpenter  work — interior  finish. 

Cabinets,  cases,  fixtures,  etc. 

Painting. 

Interior  decorative1  painting  and  plain  wall  treatment. 

Glass  and  glazing. 

Magnesia  composition  stair  covering. 

Marble  work. 

Vitrified  tile  floors. 


156  HOSPITAL    ARCHITECTURE 

Terrazzo  tile  floors,  plinths,  and  baseboards. 

Weather  strips. 

Screens. 

Hardware. 

Per  Cubic  Foot. 

Cost  of  all  above  items S116,000    or  22J  cents. 

Plumbing,  drains,  and  septic  tank 16,000     or    3|     ' 

Boilers,  heating,  and  ventilating 11,000    or  approx.  2j  cents. 

Electric   wiring,  signalling  systems,  and  telephones, 

less  than 1  cent. 

The  remaining  items  make  up  the  total  of 32  cents. 

A  duplicate  electric  generating  plant  would  cost S5500 

A  six-ton  refrigerating  and  ice-making  plant 3500 

A  refrigerated  drinking-water  system 1250 

The  stone  columns,  carving,  and  terra-cotta  embellishments  amount  to 
1  cent  per  cubic  foot. 

As  stated,  the  European  publications  are  of  little  value  in  the  building  of 
American  hospitals.  Some  of  the  best  material  on  hospital  planning  has  been 
published  in  the  architectural  periodicals,  such  as: 

Mr.  Bertrand  E.  Taylor's  article  in  the  "Brick  Builder,"  1903  and  1904. 

The  "Hospital  Unit,"  by  Geo.  H.  M.  Rowe,  M.  D.,  "Brick  Builder,"  August,  1904. 

Illustrations  in  the  "American  Architect": 

"Brick  Builder." 

"Architectural  Review." 

"Architecture." 

"International  Hospital  Record." 
"The  Planning  of  Hospitals,"  Ernest  Flagg,  "Brick  Builder,"  May  and  June,  1903. 
"The  Orientation  of  Hospital  Buildings,"  William  Atkinson,  "Brick  Builder,"  July,  1903. 
The  "Brick  Builder,"  Xo.  9,  vol.  xix.. 
Notes  on  "Planning  Hospitals,"  Dr.  S.  S.  Goldwater. 

Also  on  the  use  of  an  "Elastic  Ward  in  the  Construction  of  Hospitals  for  Contagious  Diseases." 
"Planning  of  Children's  Hospitals,"  Dr.  Charles  Butler,  No.  8,  vol.  ix,  "Brick  Builder." 

A  complete  list  of  these  for  the  past  twelve  years  can  be  found  in  the  "Quarterly 
Bulletin  of  the  American  Institute  of  Architects,"  compiled  by  Glenn  Brown, 
Secretary,  the  "Octagon,"  Washington,  D.  C,  containing  an  index  of  literature 
from  the  publication  of  architectural  societies  and  periodicals  on  architecture  in 
which  hospitals  have  a  classification. 

The  following  are  valuable  contributions  to  the  literature  of  hospitals: 

"A  Preliminary  Report  Concerning  the  Construction  of  Hospitals  for  Children,"  Chas.  P. 
Emerson,  M.  D.,  Baltimore,  Md. 

"Three  Special  Clinical  Hospitals  of  the  University  of  Breslau,  German}',"  Edmund  Wheel- 
wright. 

"Small  Hospitals  and  Suggestions  for  Hospital  Architecture,"  A.  Worcester  and  Wm.  Atkin- 
son, John  Wilev  &  Sons,  1S94. 

"Healthy  Hospitals,"  Sir  Douglass  Galton,  Oxford,  "The  Clarendon  Press,"  1S93. 

"Rudolph  Yirchow  Krankenhaus,"  vol.  vi.,  Neubauten  der  Stadt,  Berlin,  Ernest  Wasmuth, 
Berlin,  1907. 

"Handbuch  der  Architektur,"  Stuttgart,  1903. 

"Zeitschrift  fur  Krankenanstalten"  (periodical),  Leipzig,  F.  Leineweber. 


PART   II 
EQUIPMENT   OF  THE   HOSPITAL 


As  the  equipment  of  the  hospital  includes  everything  that  goes  inside  the  insti- 
tution after  the  architect  has  turned  it  over  to  the  administration,  it  will  be  neces- 
sary to  adopt  a  system  by  which  we  can  discuss  items  of  equipment  under  general 
headings. 

FIXED  FURNISHINGS 

Let  us  begin  with  the  discussion  of  those  things  which,  while  hardly  a  part  of 
the  architecture  of  the  building,  are  yet  permanent  fixtures  in  it.  Under  the  section 
headings  of  Architecture  we  have  already  discussed  the  plumbing,  refrigeration 
apparatus,  steamfitting,  electric  lighting,  and  fixtures.  We  have  not  discussed, 
for  instance,  the  vacuum-cleaning  apparatus,  dishwashing  machinery,  sterilizers 
for  ordinary  purposes,  laundry  chutes,  linen-counting  rooms,  blanket  warmers, 
towel  driers,  mattress  sterilizers,  and  the  apparatus  for  disinfecting  and  cleaning 
patients'  clothing.  We  will  discuss  these  under  their  several  headings  as  briefly 
and  concisely  as  possible. 

Vacuum  Cleaners. — At  the  outset  of  a  discussion  of  vacuum  cleaning,  as  applied 
to  institution  work,  it  will  be  profitable  to  summarize  the  many  forms  of  cleaning 
that  must  be  done.  Dust  must  be  removed  daily  from  the  floors  of  the  institution ; 
this  includes  scraps  of  paper,  stray  threads,  and  odds  and  ends  of  all  sorts  that  will 
accumulate  during  the  day,  both  wet  and  dry.  Rugs  and  carpets  must  be  gone 
over  lightly  daily,  and  at  intervals  they  must  be  thoroughly  cleaned.  The  furniture 
of  the  room  must  be  dusted;  this  includes  tables,  chairs,  dressers,  and  whatever 
upholstered  furniture  there  may  be.  The  window-sills  and  the  cracks  about  the 
windows  must  be  cleaned  of  their  dust  daily.  Walls  and  ceilings  must  be  cleaned 
at  least  periodically.  Mattresses  and  couches  must  be  cleaned  occasionally,  and 
the  interstices  of  the  radiators  must  be  cleaned.  What  part  of  this  work  will  the 
vacuum  cleaner  accomplish  in  the  present  state  of  that  art? 

Let  us  first  see  what  the  vacuum  cleaner  is,  and  how  it  works;  briefly,  it  is  an 
air-tight  chamber,  at  one  side  of  which  an  electrically  operated  fan  is  mounted. 
When  the  fan  revolves  the  air  in  the  chamber  is  withdrawn,  leaving  the  sem- 
blance of  a  vacuum.  The  pipes. or  hose  culminating  in  the  halls  and  on  the  floors 
lead  to  the  chamber,  and  the  creation  of  a  vacuum  in  the  chamber  causes  a  suction 
at  the  pipe  terminals.  A  specially  devised  "tool"  of  one  shape  or  another  is  attached 
at  the  pipe  terminal,  and,  by  reason  of  its  shape  or  construction,  picks  up  the  dirt 
or  debris  over  which  it  passes,  and  carries  it  to  the  vacuum  chamber  downstairs. 
The  integrity  of  the  "tool"  depends  on  a  more  or  less  tightly  closed  mouth  or  lips 
about  the  article  to  be  drawn  in.  Just  before  reaching  the  vacuum  chamber  the 
dirt  must  pass  over  a  screen  of  gauze  or  loosely  woven  cloth,  and  it  is  caught  and 
held  in  the  screen,  to  be  carted  away  later  on. 

157 


158  EQUIPMENT    OF    THE    HOSPITAL 

There  are  all  sorts  of  refinements  of  this  grossly  described  mechanism  in  the 
many  vacuum  cleaners  on  the  market,  and  the  various  makers  claim  virtues  for 
their  machines  in  many  directions.  It  must  be  seen  at  a  glance  that  any  differences 
between  them  must  be  due,  first,  to  strength  of  suction  in  the  air  chamber;  or,  second, 
to  differences  in  the  shape  of  the  "tools"  employed,  that  will  permit  a  wider  range 
of  usefulness  in  pulling  power. 

The  vacuum  cleaner  will  remove  only  the  dirt  that  is  perfectly  dry  and  freely 
movable;  it  will  not  remove  mud  or  wet  dirt;  this  means  that  the  dust  on  the  floor 
can  be  drawn  into  the  vacuum  if  the  proper  tool  is  employed.  The  carpets  can  be 
well  cleaned  by  the  vacuum,  including  the  dirt  on  the  floor  underneath  them. 
Mattresses  and  the  couches  can  be  very  nicely  cleaned  if  the  proper  tool  is  employed. 
The  furniture  cannot  be  cleaned  at  all  by  any  vacuum  system  in  existence  to-day, 
and  is  quite  certain  to  be  scratched  by  the  metal  tools.  Some  of  the  dust  in  the 
window  seats  and  about  the  crevices  in  the  walls  can  be  removed  by  the  vacuum. 
A  very  small  part  of  the  dust  adherent  to  the  walls  and  ceilings  about  the  pictures 
and  about  the  picture  moldings  can  be  removed,  but  the  greatest  possible  care 
must  be  taken,  since  the  vacuum  tool  will  serve  only  to  rub  in  whatever  soot  may 
be  present,  and  the  wall  will  be  streaked  and  look  all  the  worse  for  its  use.  In 
some  of  the  systems  of  vacuum  cleaning  there  is  a  double  pipe  employed,  by  which 
air  cannot  only  be  drawn  out  of  the  room,  but  forced  into  the  room ;  especially  in 
the  smaller  portable  machines  there  is  an  arrangement  for  employing  both  vacuum 
and  air-pressure,  one  to  blow  the  dust  from  the  radiator  interstices,  and  the  other 
to  suck  it  into  the  vacuum  as  it  flies  through  the  air.  Almost  all  the  loose  dirt 
in  the  room  can  be  removed  by  a  minimum  of  labor  on  the  part  of  a  very  few  people 
in  the  institution  working  a  vacuum  apparatus,  but  the  loose  dirt  is  only  a  small  part 
of  the  cleaning  to  be  done,  and  it  is  necessary  to  go  over  everything  that  the  vacuum 
cleaner  has  already  gone  over  if  we  are  to  have  a  clean  room.  Of  course,  there  will 
be  less  dirt  to  remove  by  hand,  and,  in  proportion  to  the  frequency  with  which  we 
go  over  the  room  with  the  vacuum  cleaner,  will  we  have  less  dirt  to  contend  with 
everywhere;  for  instance,  it  will  do  very  little  good  to  dust  a  room  with  a  feather 
duster  if  we  merely  drive  the  dust  from  one  place  to  another,  but  it  would  do  a  good 
deal  of  good  if  we  drove  the  dust  with  a  feather  duster  from  the  furniture  and  fix- 
tures and  walls  onto  the  rugs  and  floors,  and  then  cleaned  it  from  those  places  with 
a  vacuum  tool. 

If  one  inquires  of  the  great  mercantile  houses  whether  or  not  the  vacuum  cleaner 
is  a  satisfactory  device  in  their  own  business  houses,  one  will  get  as  many  answers 
as  there  are  kinds  of  business.  For  instance,  the  furniture  house  will  say  that  the 
vacuum  cleaner  is  of  practically  no  use  because  it  will  not  dust  furniture,  but  the 
department  store  manager  finds  that  it  fills  a  real  place  in  the  house.  He  will 
tell  you  that  piles  of  goods  on  shelves  can  be  pretty  well  cleaned  by  the  suction  of 
the  vacuum  cleaner,  and  that  this  can  be  done  without  raising  more  dust  to  settle 
on  the  goods  elsewhere.  He  will  tell  you,  moreover,  that  vacuum  cleaning  can  be 
done  in  the  daytime,  even  when  customers  are  in  the  house,  without  any  noise  or 
dust,  and,  if  the  store  is  a  very  large  one,  there  will  be  a  great  lighting  bill  saved, 
because,  when  the  janitors  get  to  work  in  department  stores  at  night,  the  place  must 
be  well  lighted  for  several  hours,  and  the  lighting  of  a  big  store  costs  a  good  deal  of 
money.  In  one  department  store  the  manager  had  made  the  statement  that  the 
vacuum  cleaner  saves  them  about  $1000  per  month  in  the  preservation  of  goods, 
in  the  saving  of  lighting  bills,  and  in  cutting  down  the  number  of  janitors  employed. 

A  great  deal  of  saving  can  be  accomplished  also  in  the  large  hotels,  especially 
where  they  have  carpets  all  over  the  floors,  not  only  in  the  rooms,  but  in  the  corri- 


FIXED    FURNISHINGS  159 

dors,  banquet  halls,  reception  rooms,  and  parlors.  In  one  such  house  there  are 
75,000  yards  of  carpet  to  be  cleaned,  and  if  the  vacuum  cleaner  did  nothing  else 
it  would  be  invaluable  here  for  carpet  cleaning. 

The  same  would  not  be  true  in  a  hospital,  or  in  any  institution  in  which  the 
sick  or  ailing  are  cared  for.  There  are  no  carpets  on  the  floors;  if  there  are  rugs 
at  all  they  are  small,  and  easily  taken  out  to  some  central  point  to  be  cleaned. 
There  are  no  tapestried  curtains,  few  if  any  pictures  on  the  walls,  and  little  or  no 
upholstered  furniture,  so  that  the  vacuum  cleaning  would  be  confined  to  the  floors 
and  walls  and  rugs.  The  rugs  could  be  taken  outside  somewhere,  perhaps  to  the 
roof,  and  that  much  of  the  dirt  would  be  thus  removed  from  the  room. 

So  that,  after  all  of  the  pros  and  cons  are  considered,  we  may  sum  up  the  situ- 
ation by  saving  that  an  institution  may  be  kept  very  much  cleaner  by  the  use  of 
the  vacuum  system,  but  practically  the  same  amount  of  cleaning  will  have  to  be 
done  by  hand  in  any  event,  and  the  janitor  service  of  the  institution  will  cost  prac- 
tically the  same  as  it  did  before  the  vacuum  was  installed,  but  the  house  will  be  kept 
a  good  deal  cleaner,  though  at  an  additional  cost — cost  of  installation  of  the  machine, 
cost  of  the  power  to  run  it,  and  cost  of  extra  help  to  operate  it. 

These  arguments,  pretty  generally  known,  have  been  sufficient  to  deter  the  aver- 
age hospital  or  institution  administrator  from  installing  a  vacuum-cleaning  system 
in  the  past,  because  the  expense  of  such  installation  has  been  great,  costing  any- 
where from  SI 000  to  S3000  or  $4000,  according  to  the  size  and  architecture  of  the 
building  to  be  installed. 

Recently  there  has  been  placed  on  the  market  a  portable  vacuum  cleaner,  the 
best  of  the  kind  perhaps  being  made  by  the  Duntley  Manufacturing  Co.,  a  Chicago 
corporation,  and  this  machine  has  proved  quite  satisfactory  in  homes  and  apart- 
ment houses,  and  small  hotels  and  some  hospitals  and  similar  institutions  have  either 
installed  them  or  considered  doing  so.  The  principal  defect,  and  one  that  must 
settle  the  matter  for  the  hospital  administrator  at  least,  is  the  prohibitive  amount 
of  noise  made  by  the  portable  motor  in  operating.  In  the  home  or  in  the  hotel  this 
noise  is  made  in  the  daytime,  when  occupants  are  away,  and  consequently  cuts 
very  little  figure.  In  the  hospital  or  institution  the  noise  is  intolerable,  and  cannot 
be  thought  of. 

Very  recently  this  same  company  is  installing  a  modification  of  the  portable 
vacuum  cleaner  that  is  simply  the  portable  machine  on  a  very  much  larger  scale, 
located  at  some  point  in  the  basement,  from  which  noises  cannot  travel  readily, 
and  connected  to  the  floors  upstairs  by  pipe  lines  capable  of  being  installed  at  a 
very  moderate  expense  and  run  up  elevator  shafts.  This  machine  costs  only  $300 
or  $400,  and  is  large  enough  to  permit  two  outlets  to  be  wrorked  at  a  time;  a  line 
of  pipe  can  be  sent  up  as  high  as  six  stories,  at  a  cost  of  something  less  than  $50, 
and  it  can  be  tapped  on  each  floor.  Such  an  installation  is  comparatively  econom- 
ic, and  even  if  it  did  no  more  than  clean  the  rugs  and  pull  the  dirt  from  the  mat- 
tresses, it  would  pay  to  employ  one  or  two  men  at  this  work;  at  least  one  such  in- 
stallation is  working  satisfactorily. 

Blanket  Warmers. — Of  all  the  semifixed  furnishings  of  an  institution  there 
will  hardly  be  an  item  that  will  give  more  satisfaction  than  the  ordinary  laundry 
drier,  built  in  the  wall,  for  the  purpose  of  warming  blankets,  or  for  the  occasional 
drying  of  wet  linens,  towels,  or  dressings.  This  apparatus  is  nothing  more  nor  less 
than  a  chamber  in  the  wall,  about  14  inches  wide,  S  feet  high,  and  about  8  feet  deep. 
There  is  an  ordinary  steam-coil  at  the  back  that  must  not  be  attached  to  the  heat- 
ing apparatus  of  the  house,  because  blankets  should  be  kept  hot  winter  and  sum- 
mer, and  it  will,  therefore,  be  necessary  to  have  the  coil  attached  to  the  power- 


160 


EQUIPMENT   OF   THE    HOSPITAL 


house  itself,  or  to  the  steam-service  pressure  line  that  serves  the  steam  tables  and 
sterilizers,  or  if  there  is  a  system  of  these  blanket  warmers,  the  piping  will  be  an 


Fig.  70. — Blanket  warmer. 

easy  matter.  The  warmers  should  be  in  the  operating  suite  and  off  the  wards  and 
dressing  rooms.  They  may  be  built  of  tile,  plastered  and  white  enameled  inside 
(Fig.  70). 


STERILIZERS  FOR  INSTITUTION  USE 

In  discussions  of  the  administrative  operations  of  the  general  hospital  it  will  be 
necessary  to  take  up  the  questions  of  prevention,  disinfection,  and  isolation  as 
administrative  problems,  and  the  methods  by  which  to  achieve  the  best  results. 
At  this  time  we  are  discussing  merely  the  equipment  of  the  institution,  and  will, 
therefore,  entertain  only  the  question  of  the  destruction  of  the  pathogenic  micro- 
organisms and  the  mechanism  devised  for  that  purpose. 

Every  institution,  whether  it  be  a  general  hospital  or  an  asylum,  school,  acad- 
demy  or  hotel,  or  a  ship  that  sails  the  seas,  must  be  equipped  for  the  destruction 
of  one  or  several  forms  of  pathogenic  micro-organisms,  parasites,  or  vermin.  To- 
day, in  the  light  of  what  we  know  about  these  forms  of  microscopic  life,  we  have 
settled  down  to  one  of  three  destroying  agents — heat,  gases,  or  chemic  solutions. 


STERILIZERS    FOR    INSTITUTION'    USE  1G1 

Chemic  solutions  and  the  gases  have  special  applications,  and  need  not  now  be 
thought  of.  To  use  either  of  them  in  a  general  way  no  special  apparatus  is  required. 
The  other  form  of  disinfection — namely,  heat — requires  special  equipment,  made  to 
accommodate  the  material  to  be  sterilized.  It  is  not  the  purpose  in  this  con- 
nection to  discuss  the  physics  of  heat  or  the  physical  changes  that  occur  when  heat 
destroys  micro-organisms.  These  discussions  have  a  place  in  works  on  physics 
and  in  books  on  engineering.  Suffice  it  for  us  to  recognize  certain  physical  facts 
that  are  the  result  of  long  experience  in  the  engineering  profession;  nor  are  we  here 
to  design  sterilizers,  but  to  place  ourselves  in  possession  of  sufficient  information 
concerning  their  principles  and  mechanism  to  enable  us  to  buy  the  proper  sterilizer 
for  the  purpose  intended. 

There  are,  grossly  speaking,  four  forms  of  heat  sterilization:  one  contemplates 
the  use  of  dry  heat  only;  a  second  employs  hot  water;  a  third,  moist  heat  in  motion, 
that  is,  streaming  steam ;  and  a  fourth  contemplates  the  employment  of  steam  under 
pressure  in  connection  with  a  mechanism  to  create  a  vacuum  at  certain  points  of 
the  process,  with  a  view  to  enable  the  steam  to  penetrate  to  all  parts  of  the  con- 
taining device,  and  thus  destroy  all  micro-organic  life  resident  there. 

There  are  two  fundamental  objections  to  the  employment  of  mere  dry  heat, 
no  matter  at  what  temperature  it  may  be  supplied:  the  principal  objection  is  that 
dry  heat  penetrates  such  material  as  woolen  and  cotton  goods  and  packed  hair, 
such  as  mattresses,  very  slowly,  and,  if  it  is  carried  at  a  temperature  sufficient  to 
destroy  life  when  it  arrives  at  the  spot,  it  is  also  of  sufficiently  high  temperature  to 
destroy  most  fabrics,  especially  woolens.  Therefore  we  have  practically  given  over 
any  attempt  to  sterilize  by  the  use  of  dry  heat  alone,  and  use  it  instead  merely  as 
a  drying  process,  in  what  we  shall  hereafter  describe  as  the  vacuum  system  of 
sterilization.  Boiling  water  has  physical  disadvantages  that  limit  its  use  to  very 
special  purposes,  such  as  the  sterilization  of  the  rougher  utensils  of  the  sick  room, 
as  bed-pans  and  urinals. 

There  are  two  forms  in  which  steam  is  employed  in  sterilization,  whether  it  be 
as  streaming  steam  or  in  the  vacuum  devices,  namely,  saturated  steam  and  super- 
heated steam.  Contrary  to  the  usual  understanding,  saturated  steam  need  not 
necessarily  be  just  at  the  temperature  of  boiling  water,  that  is,  the  temperature  at 
which  water  is  changed  into  steam.  It  may  be  of  any  temperature,  but  by  the  term 
"saturated  steam"  we  mean  the  initial  temperature,  and  consequently  the  initial 
pressure  at  which  steam  leaves  the  water  container  as  it  is  volatilized.  Super- 
heated steam  is  steam  that  has  left  its  water  reservoir  as  saturated  steam,  but 
whose  pressure  has  secondarily  been  tremendously  increased  by  further  applica- 
tion of  heat. 

There  is  no  doubt  that  saturated  steam  at  a  given  temperature,  and  hence  a 
given  pressure,  has  a  greater  power  of  penetration  than  superheated  steam  at  the 
same  pressure.  In  the  case  of  saturated  steam,  however,  there  is  a  greater  tendency 
toward  condensation  than  in  superheated  steam,  and  consequently  the  last  process 
of  sterilization  in  the  use  of  steam — that  is,  of  drying — is  rendered  more  difficult 
and  requires  more  time;  hence  the  total  time  employed  to  sterilize  goods  and  make 
them  again  ready  for  use  will  be  greater  if  saturated  steam  is  employed  than  it" 
the  steam  is  superheated.  But  the  fact  that  superheated  steam  has  a  less  pene- 
trating power,  because  of  its  drier  physical  condition,  is  almost  or  completely  offset 
by  the  fact  that  its  higher  potential  temperature  is  capable  of  greater  and  quicker 
destruction  when  once  it  does  penetrate,  and  by  the  further  fact  that  fabrics  can 
be  dried  in  the  container  more  readily  because  they  are  not  so  wet  at  any  stage  of 
the  process. 


162  EQUIPMENT    OF    THE    HOSPITAL 

Some  makers  of  sterilizing  apparatus  are  fond  of  making  diagrams  showing  the 
container  with  a  great  volume  of  steam  under  pressure,  occupying  all  the  space 
excepting  an  infinitesimal  point  at  the  center  of  the  apparatus,  and  a  good  deal  is 
made  of  the  fact  that  this  central  point,  however  small  it  may  be,  is  capable  of  pro- 
tecting a  sufficient  number  of  micro-organisms  to  start  an  entirely  new  infection 
of  the  material  in  the  container  almost  immediately  the  heat  is  removed.  Those 
manufacturers  whose  apparatus  calls  for  a  constant  moving  volume  of  steam  from 
one  end  of  the  cylinder  to  another  insist  that  there  can  be  no  point,  however  infini- 
tesimal, that  will  escape  the  penetrating  of  the  moving  steam,  providing  there  is 
an  opening  at  some  dependent  portion  of  the  container  to  allow  all  the  latent  air 
to  escape,  and  hence  to  allow  all  the  space  in  the  container  to  be  occupied  by  the 
steam. 

Those  of  us  who  have  followed  the  logic  of  the  makers  of  the  various  forms  of 
sterilizing  device  have  merely  arrived  at  a  stage  of  indetermination,  and  have 
achieved  possibly  less  knowledge  from  our  reading  than  if  we  had  merely  used  our 
common  sense.  But  those  of  us  who  have  prosecuted  our  investigations  to  the 
point  of  actual  experiments,  using  the  ordinary  materials  that  we  have  to  sterilize 
artificially  infected  with  some  special  form  of  pathogenic  micro-organism,  have 
come  to  almost  a  unanimous  conclusion  that,  given  a  container  that  will  allow  of 
the  invasion  of  a  volume  of  steam,  saturated  or  superheated,  if  it  be  under  a  pres- 
sure of,  say,  15  to  18  pounds — that  is,  at  a  temperature  of  250°  to  275°  F. — and  if 
this  steam  can  be  circulated  in  the  container  for  a  sufficient  length  of  time,  we  can 
achieve  actual  practical  sterilization  in  almost  any  apparatus  now  offered  on  the 
market  for  sale. 

A  clear  warning  must  be  sounded,  in  effect,  that  no  apparatus,  under  any  con- 
ditions whatsoever,  should  be  accepted  on  the  assumption  that  it  will  do  what  is 
claimed  for  it  until  actual  experiments  have  been  made,  and  those  of  us  who  are 
very  particular  about  our  sterilization,  especially  in  the  sterilization  of  opera- 
ting-room material,  are  in  the  habit  of  periodically  and  frequently  making  plants 
of  pathogenic  micro-organic  cultures,  and  placing  them  at  the  core  of  a  package 
of  material  which  we  know  to  be  difficult  of  sterilization,  and,  if  those  hardy  micro- 
organisms can  be  wholly  destroyed  under  specially  difficult  conditions,  then  we 
accept  that  sterilizer  and  the  work  we  are  doing  with  it  as  a  sufficient  steriliza- 
tion. It  is  not  likely  that  we  shall  have  anthrax  and  tetanus  or  their  spores  to 
deal  with  ordinarily,  but  no  sterilization  can  be  considered  efficient  unless  it  is  a 
spore  destroyer,  for  it  is  those  hardy  micro-organisms  that  will  occasionally  upset 
all  our  fine  calculations.  It  is  not  sufficient  that  we  make  these  plants  and  esti- 
mate the  effect  of  our  sterilization  once,  at  the  time  of  purchase  of  the  apparatus, 
because  a  hinge  on  the  sterilizer  may  loosen,  or  the  seat  may  dry  out,  or  a  leak 
may  occur  almost  anywhere,  in  which  case  the  sterilization  will  not  be  complete, 
and  our  first  warning  of  the  fact  may  be  some  grave  postoperative  infection. 

THE  VARIOUS  STERILIZERS 

Beginning  with  the  largest  sterilizer  that  we  will  be  called  upon  to  use,  we 
have  that  huge  piece  of  mechanism  usually  confined  to  the  basement  of  the  insti- 
tution, and  which  we  call  the  mattress  sterilizer  or  disinfector,  used  not  only  for 
the  sterilization  of  mattresses,  but  for  patients'  clothing,  blankets,  rugs,  and  the 
like.  Then  we  have  the  utensil  sterilizer,  used  to  sterilize  ward  utensils,  bed-pans, 
basins,  and  urinals.  There  is  also  the  linen  sterilizer,  a  mechanism  devised  espe- 
cially for  the  disinfection  or  sterilization  of  the  bed-clothing  and  bedding  of  infected 


STERILIZERS    FOR    INSTITUTION    USE  L63 

patients  before  they  can  be  sent  to  the  laundry.  There  is  likewise  the  excreta 
sterilizer,  a  mechanism  devised  to  destroy  infected  stools,  urines,  and  sputa  of 
patients  suffering  from  typhoid  fever,  tuberculosis,  and  the  exanthemata.  Then 
we  have  the  dressing,  instrument,  and  water  sterilizers  in  the  operating  depart- 
ment of  the  hospital.  In  the  diet  kitchen  we  have  the  autoclave  for  the  steaming 
and  disintegration  of  foods  that  go  to  make  up  certain  special  diets,  and  a  similar 
device  lias  a  place  in  the  laboratory  of  pathology  for  the  purpose  of  destroying 
micro-organisms  for  vaccines  and  for  similar  purposes.  All  these  devices  arc  in- 
tended to  achieve  a  single  result,  that  is,  the  destruction  of  pathogenic  micro- 
organisms, and  they  arc  made  in  different  forms  to  accommodate  the  materials 
intended  to  be  sterilized  in  them.     Let  us  first  take  the  mattress  sterilizer. 

Mattress  Sterilizer. — This  mechanism  has  reached  a  stage  of  great  usefulness 
in  institution  administration.  Its  primary  requirements  are  that  it  shall  be  large 
enough  to  contain  several  mattresses  at  a  time,  and  yet  it  must  be  small  enough  to 
be  economic  in  the  point  of  steam  usage.  It  must  be  strong  enough  to  withstand 
the  necessary  steam  pressure  to  bring  the  temperature  up  high  enough  to  destroy 
even  the  hardiest  of  the  pathogenic  micro-organisms.  It  must  be  so  arranged 
that  infected  mattresses,  bedding,  and  patients'  clothing  can  be  put  into  it  and 
sterilized,  and  then  removed  without  danger  of  reinfection.  This  means  that  the 
mattress  sterilizer  must  have  an  entrance  door  at  one  end  and  an  exit  door  at  the 
other,  and  the  entrance  door  must  open  into  one  compartment  wholly  separated 
from  the  compartment  into  which  the  exit  door  opens;  the  mechanism,  more- 
over, must  be  simple,  so  that  the  ordinary  houseman  can  manipulate  its  valves 
without  danger  of  injury  either  to  himself  or  others  or  to  the  apparatus. 

Some  of  these  large  sterilizers  are  made  with  a  door  smaller  than  the  inside 
diameter  of  the  vault  itself,  but  it  is  extremely  difficult  to  get  a  thick,  heavy  mat- 
tress into  it,  although,  after  it  is  inside,  there  is  plenty  of  room  and  to  spare;  this 
means  that  entirely  too  many  cubic  feet  of  steam,  under  the  necessary  pressure, 
will  have  to  be  employed  to  sterilize  the  material  that  the  doors  allow  to  enter. 
This  is  especially  true  with  the  cylindric  devices;  but,  even  if  the  door  is  made  the 
same  size  as  the  cylinder  itself,  the  shape  of  the  vault  in  the  cylindric  types  is  not 
adapted  to  hold  as  many  mattresses  as  the  cubic  area  will  take  care  of,  and  there 
will  be  a  good  deal  of  unoccupied  space.  Most  institutions  have  a  uniform  size 
of  bed  throughout,  and  there  will  be  a  uniform  size  of  mattresses.  When  this  is 
the  case  it  will  be  easy  to  select  the  mattress  sterilizer  of  the  right  dimensions. 
For  instance,  the  average  hospital  will  hardly  have  any  mattresses  that  will  be 
more  than  42  inches  wide,  8  inches  thick,  and  78  inches  long,  so  that  a  sterilizer 
with  inside  measurements  of  84  inches  long,  48  inches  high,  and  48  inches  wide 
(which  is  a  standard  size)  will  accommodate  four  mattresses  comfortably  standing 
on  edge. 

In  the  best  institutions  now  all  the  clothing  of  free  patients  and  of  those  not 
very  clean  is  sterilized  before  being  bundled  for  the  lockers.  If  the  bundles  are 
put  in  the  sterilizer  they  are  very  certain  to  come  out  damp,  no  matter  how  much 
care  is  taken  in  the  drying  part  of  the  process,  and,  when  they  are  called  for,  on  the 
discharge  of  the  patient,  they  will  be  found  ruined.  If,  on  the  other  hand,  they  are 
sterilized  separately,  and  thoroughly  dried  before  being  bundled,  they  will  keep 
nicely  for  an  indefinite  time.  The  cylindric  sterilizer  lias  no  conveniences  for 
hanging  clothes  inside.  The  48  by  48  by  84  inches  rectangular  sterilizer,  on  the 
other  hand,  has  a  rack  made  partly  for  a  "clothes-horse" ;  if  the  pieces  of  clothing 
are  fastened  with  metal  clothes-pins,  each  bar  of  the  rack  will  hang  all  the  clothing 
of  one  patient,  and,  as  there  are  eight  of  these  liars,  two  in  each  division,  the 


164 


EQUIPMENT    OF    THE    HOSPITAL 


clothing  of  eight  patients  can  be  sterilized  at  one  time.  The  rectangular  apparatus 
has  usually  a  formaldehyd-ammonia  disinfecting  device  for  clothing  that  cannot 
be  subjected  to  wet  heat,  such  as  felt  hats  and  shoes,  and  these  articles  can  be 
sterilized  altogether  and  without  heat. 

There  are  two  types  of  the  rectangular  mattress  sterilizer — one  made  by  the 
American  Sterilizer  Co.,  of  Erie,  Pa.,  and  the  other  by  the  Kensington  Engine  Co.,  of 
New  Jersey.  There  is  no  doubt  about  the  integrity  of  the  American  apparatus  as 
to  matei'ial  and  workmanship,  and  it  has  given  satisfaction  wherever  used.  The 
Kensington  disinfector  has  perhaps  a  more  convenient  and  more  quickly  fastened 
door  mechanism,  in  the  form  of  a  series  of  toggle  bolts,  that  spin  around  by  a  motion 
of  one  finger  until  they  are  set  home.  In  the  American,  the  door  is  fastened  by  a 
wheel  movement  similar  to  that  in  the  dressing  sterilizer;  it  takes  longer  to  fasten 


Fig.  71. — "American"  rectangular  36-inch  wide,  54-inch  high,  84-inch  long,  internal  dimen- 
sions, steam-pressure  disinfector,  complete  with  its  regular  equipment,  including  the  American 
vacuum  type  formaldehyd-ammonia  generators  with  independent  steam  generator,  by  which  arti- 
cles of  leather,  rubber,  and  other  materials  that  would  be  injured  by  steam,  can  be  disinfected  by 
formaldehyd  gas  let  into  chamber  under  a  high  degree  of  vacuum  without  any  heat  whatsoever 
in  the  jacket  of  disinfector. 


the  door  in  the  American  apparatus.  To  more  than  offset  the  inconvenience,  the 
door  carriage  of  the  American  is  a  more  substantial  and  smoother  working  device. 

The  door  seat  is  a  matter  of  a  good  deal  of  moment.  Aside  from  the  packing, 
the  seat  is  tongue  and  groove  in  form,  that  is,  there  is  a  deep  groove  all  around  the 
sterilizer  mouth,  and  opposite  this  grove  in  the  door  is  a  tongue  that  sets  deep  into 
it.  At  the  bottom  of  this  groove  is  the  packing,  which  is  a  secret  process  material 
composed  of  asphaltum  and  asbestos. 

Figure  71  is  a  photograph  of  the  American  Sterilizer  Co.'s  rectangular  mattress 
and  clothing  sterilizer.  This  apparatus  may  be  used  without  fear  of  disaster  to 
any  who  may  employ  it;  it  is  particularly  recommended  by  Dr.  James  Duncan 
Gatewood,  instructor  in  naval  hygiene  of  the  United  States  Naval  School  at  Wash- 
ington and  medical  inspector  in  the  United  States  Navy.     Dr.  Gatewood  went  into 


STERILIZERS    FOR    INSTITUTION    USE 


1G5 


this  question  of  disinfection  and  sterilization  most  completely  in  connection  with 
installation  of  sterilizers  for  battleships. 

Utensil  Sterilizers. — Every  well-equipped  institution  should  contain  a  num- 
ber of  utensil  sterilizers  located  wherever  utensils  are  cleaned.  There  is  nothing 
very  particular  that  need  be  said  about   the  utensil  sterilizer  excepting  the  foot 


Fig.  72, — "White  Line"  utensil  sterilizer. 


mechanism,  which,  in  most  types,  is  usually  nut  of  order.  The  oil-tank  escapement 
mechanism  in  some  of  the  types  is  especially  untrustworthy,  and,  after  all,  the  free 
floor  lift  with  a  notched  locking  device  is  best.  In  some  of  the  newer  patterns 
there  is  a  gaskcted  seat,  winch,  when  operated  with  a  locking  lid,  makes  a  steam- 
tight  container,  capable  of  holding  a1  leasl  5  or  (i  pounds  of  steam,  enough  to 
materially  shorten  the  time  of  sterilization.     Perhaps   the   hydraulic   lift  will  be 


166 


EQUIPMENT    OF    THE    HOSPITAL 


best  after  it  has  been  perfected,  but  it  increases  the  cost  out  of  proportion  to  its 
value. 

Figure  72  shows  the  "White  Line"  utensil  sterilizer,  made  by  the  Scanlan  Morris 
Co.,  of  Madison,  Wisconsin.  This  sterilizer  is  made  of  heavy  copper,  the  outside 
of  the  body  and  the  lid  nickel-plated;  it  is  coated  inside  with  block  tin,  and  has  the 
simple  foot-lift  for  raising  the  cover,  and  at  the  same  time  raising  up  the  metal 


Fig.  73. — "American"  (patented)  hydraulicly  operated  utensil  sterilizer,  also  method  of 
operating;  tray,  cover,  and  contents  being  elevated  by  city  water  pressure  _  acting  under 
hydraulic  plungers.  Tray,  cover,  and  contents  are  lowered  by  pressing  the  opposite  pedal,  thus 
opening  water  escape  valve. 


tray  containing  the  utensils.  There  is  a  heavy  counter-weight  attached  to  the  cover 
hinge  that  holds  the  cover  up  after  it  is  raised  by  the  foot-lift.  There  are  other 
sterilizers  of  almost  the  same  pattern,  but  with  a  different  lifting  device  and  differ- 
ent control,  that  seem  not  to  be  so  convenient  of  operation,  as,  for  instance,  that 
particular  mechanism  in  which  the  cover  and  tray  are  raised  by  the  turn  of  a  valve. 
This  necessitates  using  the  hand,  not  always  a  desirable  thing  to  do. 


STKHILIZKKS    I'OK    I  XSTITITII  )\     USE 


167 


Figure  73  shows  the  American  Sterilizer  Co.'s  utensil  sterilizer.  This  is  also 
a  most  excellent  mechanism.  The  cover  and  tray  are  raised  and  lowered  by  foot 
pedal,  and  there  is  an  added  simplicity  in  this  device  by  reason  of  the  few  valves 
to  be  employed,  but  the  Scanlan  Morris  mechanism  has  the  greater  advantage  of 
the  tight  water-seal  connection  between  the  cover  and  the  container. 

Typhoid  Stool  and  Urine  Sterilizer. — Figure  74  shows  a  diagram  of  a  stool 
sterilizer  made  by  the  American  Sterilizer  Co.,  the  best  device  of  the  kind  at  this 
time,  when  all  the  types  are  unsatisfactory.  It  is  almost  automatic  in  its  operation, 
the  pan  being  merely  set  into  the  machine,  caught  by  a  moving  arm,  upset  and 
emptied,  then  washed,  then  sterilized  automatically,  the  process  including  the  total 


Fig.  74. — "American"  stool  sterilizer. 


destruction  of  the  micro-organisms  in  the  contents  of  the  pans  by  the  steam  that 
is  released  into  the  chamber.  This  device  has  not  yet  reached  a  very  high  state 
of  perfection,  but  heretofore  we  have  had  to  treat  the  contents  of  pans  and  urinals 
to  a  disinfecting  solution  of  carbolic  acid  or  bichlorid  for  several  hours,  ami,  in 
addition,  sterilize  the  vehicles  themselves  in  the  ordinary  utensil  sterilizer,  so  that 
the  composite  sterilizer  is  an  actual  advance. 

There  are  other  forms  of  typhoid  stool  sterilizers  that  arc  quite  as  unsatisfac- 
tory as  the  one  described  above.  One  of  these  is  in  use  in  the  Massachusetts 
General  Hospital,  another  was  designed  for  the  Lakeside  Hospital,  Cleveland. 
The  Hospital  Supply  Company,  of  New  York,  makes  one,  ami  one  is  now  under 
construction  by  the  Scanlan  Morris  Co.,  of  Madison,  Wisconsin. 


168 


EQUIPMENT    OF   THE    HOSPITAL 


All,  excepting  the  last  named,  consist  of  a  cast-iron  chamber  equipped  for  a  jet 
of  low-pressure  steam  and  hot  water. 

Dr.  Washburn,  of  the  Massachusetts  General  Hospital,  has  redesigned  his 
hopper,  by  giving  it  a  double  jacket  down  to  the  shut-off  valve.  The  process  con- 
sists in  letting  in  steam  and  hot  water  up  to  a  certain  point.  Dr.  Hurd,  of  Johns 
Hopkins  Hospital,  in  attempting  to  use  this  hopper  found  it  impossible  to  keep  it 
from  overflowing  and  making  a  mess  on  the  floors.  He  finally  dispensed  with  its 
services.  They  are  still  using  it  in  the  Massachusetts  General  Hospital,  although 
they  find  it  necessary  to  use  in  addition  a  copper  tank  in  which  to  boil  the  bed-pan 
and  urinal  after  emptying  the  contents  into  the  hopper.     Altogether  this  makes  a 

most  cumbersome  affair,  and  requires 
great  attention  to  details  for  its  suc- 
cessful carrying  out.  It  is  made  by  E. 
B.  Badger  &  Co.,  Boston  (Fig.  75). 

The  Scanlan  Morris  Co.  has  now 
in  course  of  construction  a  high-pres- 
sure zinc-jacketed,  cast-steel  hopper, 
porcelain  lined  and  porcelain  covered. 
Its  working  mechanism  consists  of  a 
high-pressure  steam  jet,  with  pressure 
valve  and  automatic  hot-water  shut 
off.  There  is  a  steam  pipe  leading 
from  the  hopper  to  an  exit,  either  at 
the  roof  or  into  a  sewer  catch.  Into 
this  steam  escape  pipe  is  placed  a 
high-pressure  cock  with  automatic  shut 
off,  and  also  a  trap  for  condensation, 
controlled  by  a  small  pet  cock  at  the 
bottom. 

Linen  Sterilizers. — Manufacturers 
of  sterilizing  apparatus  have  clone 
their  best  for  a  long  time  to  design 
a  mechanism  that  would  act  to- 
ward loose  linen  and  cotton  gar- 
ments and  bedclothing  as  a  dress- 
ing sterilizer  does  toward  operating 
paraphernalia;  that  is,  disinfect  it  and  subsequently  dry  it,  so  that  it  can  be  handled 
conveniently  into  the  laundry.  They  have  not  been  very  successful.  They  have 
tried  three  methods:  one  by  dry  heat,  which  has  uniformly  destroyed  the  fabrics; 
one  by  the  simple  boiling  of  the  goods  in  water;  and  the  third,  by  the  use  of  live 
steam  let  loose  inside  the  container.  There  has  been  no  trouble  in  disinfecting, 
but  no  mechanism  offered  has  as  yet  succeeded  in  drying  the  goods  for  the  laundry. 
Obviously,  any  system  of  disinfection  without  agitation  of  the  goods,  such  as  we 
obtain  in  the  laundry  washers,  will  not  take  the  dirt  out  of  the  goods,  and  the  two 
processes  are  absolutely  necessary,  either  together  or  separately. 

Both  the  large  laundry  manufacturers — that  is  the  Troy  and  the  American — 
make  what  they  call  a  disinfector,  and  they  claim  for  it  more  than  they  are  able  to 
deliver,  but  perhaps  enough  to  meet  the  requirements  until  we  can  obtain  some 
special  mechanism  that  may  be  installed  or  employed  in  the  wards  or  service  rooms 
of  the  hospital. 

The  laundry  disinfector  is  merely  a  washing  machine  of  small  type,  made  of 


Exhaust 
outlet  on 
opposite 
side  from 
steam  in- 


Fig.  75. — Badger  typhoid  stool  sterilizer. 


STERILIZERS    FOR    INSTITUTION    USE  169 

metal  with  gasket  scat  to  the  lid  and  a  locking  device,  supposed  to  control  the 
machine  up  to  about  as  high  a  point  as  the  ordinary  dressing  sterilizer.  As  a  matter 
of  fact  it  does  not  do  so. 

The  obstacles  to  be  overcome  in  designing  a  serviceable  linen  sterilizer  are 
such  that  there  promises  to  be  no  relief,  except  in  the  form  of  a  vacuum  double- 
jacketed  device  of  some  such  type  as  the  dressing  sterilizer. 

Most  hospitals  arc  still  disinfecting  their  typhoid  linens,  and  other  goods  that 
have  been  in  touch  with  communicable  disease,  in  vats  or  tanks  of  disinfecting 
solution  of  carbolic  acid  or  biehlorid,  and  leaving  them  there  the  prescribed  time — 
that  is,  over  night — because  it  seems  to  be  agreed  by  pathologists  that  the  micro- 
organisms of  the  diseases  of  childhood,  and  diphtheria,  typhoid  fever,  and  tuber- 
culosis are  then  completely  destroyed  in  a  3  per  cent,  carbolic-acid  solution  or  a 
1  :  1000  biehlorid  solution. 

In  some  hospitals  the  ordinar}'  utensil  sterilizer  is  employed  for  sterilizing 
infected  fabrics,  the  process  being  a  boiling  of  five  or  ten  minutes,  and  the  goods 
are  then  conveyed  to  the  laundry  in  a  wet  state.  This  is  a  saving  of  time  over  the 
all-night  cheniic  solution  process,  and,  in  either  event,  the  goods  go  to  the  laundry 
wet,  but  the  special  preference  for  the  boiling  process  is  that  we  have  not  to  contend 
with  the  carbolic  acid  smell  which  it  is  impossible  to  remove,  and  biehlorid  is  rather 
an  expensive  disinfector  for  use  in  that  way. 

Operating-room  Sterilizers. — Before  any  sterilizer  is  set  to  work  in  any  insti- 
tution exhaustive  tests  should  be  made  to  determine  the  definite  lethal  point  of 
the  hardiest  varieties  of  spore-forming  pathogenic  micro-organisms,  and  these 
tests  should  be  repeated  at  intervals  frequent  enough  so  that  the  surgeons  of 
the  institution  can  be  guaranteed  the  complete  sterility  of  the  articles  they  use 
in  their  operations.  All  the  mechanics  of  steam  have  not  been  mastered  by 
physicists,  and  it  so  happens  that,  for  some  inexplicable  reason,  a  sterilizer  that 
operates  perfectly  to-day  may  deteriorate  in  its  usefulness,  although  the  physical 
reasons  may  not  be  apparent;  at  least  that  has  been  the  costly  experience  of  some 
very  careful  administrators. 

Little  might  be  said  here  of  the  pro  or  con  of  the  argument  as  to  vacuum  steril- 
ization. The  whole  purpose  of  seeking  a  vacuum  in  any  sterilizer  is  to  be  secure 
the  steam  is  at  proper  pressure,  consequently  at  proper  heat  and  at  proper  moisture, 
and  in  every  part  of  the  container,  and  so  that  it  shall  invade  every  atom  of  its 
contents. 

Dressing  Sterilizer. — What  has  been  said  at  the  beginning  of  this  section  about 
the  purpose  of  steam  sterilization  is  perhaps  more  nearly  applicable  in  the  case  of 
the  dressing  sterilizer  of  the  operating  department  than  to  any  other  form  of  that 
article.  Here,  again,  it  is  the  case  of  a  vacuum,  or  no  vacuum  device,  and  without 
doubt  almost  any  of  the  sterilizers  on  the  market  are  quite  capable  of  doing  the 
work  efficiently  under  certain  well-established  conditions,  and  these  conditions  can 
be  ascertained  only  by  experiment;  it  may  be  stated  that  there  is  no  type  now  on 
the  market  that  can  be  taken  on  honor,  to  be  used  for  any  particular  purpose,  with- 
out carefully  planned  and  executed  experimentation.  1'or  instance,  the  Bramhall 
device,  in  which  the  door  works  from  the  inside  and  sets  upon  a  scat  resisting  an 
outward  pressure,  is  the  least  likely  of  all  to  get  out  of  order,  because  of  the  very 
simplicity  of  the  door  mechanism.  In  this  form  of  sterilizer  (Fig.  76)  the  greater 
the-  pressure  within  the  snugger  the  door  will  set  upon  its  seat;  and  it  has  the  ad- 
ditional advantage  of  being  free  from  danger  to  the  nurse  or  attendant  who  should 
happen  to  unlock  the  door  before  the  steam  is  all  out  ;  it  would  be  difficult  to  unseat 
a  Bramhall  door  while  there  is  enough  pressure  inside  to  seriously  burn  an  attend- 


170 


EQUIPMENT    OF    THE    HOSPITAL 


ant,  and  in  this  form  also  there  is  no  question  of  the  wearing  out  of  the  hinges  or 
hinge  bars  of  the  door,  nor  is  there  a  question  of  the  wear  and  tear  on  the  fingers  of 
a  locking  device  such  as  the  other  sterilizers  contain. 

The  great  objection  to  the  Bramhall  sterilizer  is  that  the  opening  is  consider- 
ably smaller  than  the  cylinder  itself,  as,  for  instance,  a  24-inch  cylinder  will  ordi- 
narily have  a  door  of  16  inches,  so  that  when  the  material  is  pushed  in  on  the  car- 
riage there  will  be  an  unnecessarily  large  space  to  be  occupied  by  steam  pressure, 
and  it  may  well  be  conceived  that  the  expense  of  operating  this  mechanism  on  the 
score  of  steam  alone  will  amount  to  considerable  in  the  course  of  a  year.     On  the 

other  hand,  it  seems  physically  impos- 
sible to  have  a  door  seated  like  the 
Bramhall  door  set  into  an  opening  the 
full  size  of  the  cylinder,  so  that  we 
must  accept  one  or  the  other  horn  of 
the  dilemma.  Certainly  the  Bramhall 
sterilizer  is  the  simplest  form  of  de- 
vice, and  it  may  be  doubted  whether 
one  of  that  make  will  ever  wear  out. 
Where  the  dressing  sterilizer  is  in- 
tended to  be  used  as  an  autoclave, 
either  in  the  laboratory  of  pathology 
or  in  the  diet  kitchen,  and  where  the 
demand  is  not  great,  the  question  of 
steam  is  not  an  overpowering  one, 
and  in  both  these  places  the  Bramhall 
sterilizer  has  given  perfect  satisfaction 
in  institutions  where  the  device  has 
been  in  constant  use.  It  is  true  that 
in  neither  the  laboratory  or  the  diet 
kitchen  is  the  mechanism  so  constantly 
called  upon  as  in  the  operating-  and 
dressing-rooms.  In  the  laboratory, 
for  instance,  the  autoclave  will  hardly 
be  used  for  more  than  two  or  three 
hours  a  day,  and  in  the  diet  kitchen  it 
will  perhaps  be  used  a  considerably 
shorter  time  than  this,  and  not  every 
day.  The  diet  kitchen  autoclave  is 
used  to  disintegrate  meat,  to  free  it 
from  its  extracts  by  means  of  pressure  devices,  and  to  break  up  the  myosin  and 
melt  out  the  stearin. 

The  operating-room  sterilizer  is  ordinarily  in  use  about  twelve  hours  a  day,  and 
may  be  called  on  to  do  from  fifteen  to  twenty-four  complete  sterilizations  in  the 
course  of  that  many  hours.  This  means  that  it  must  be  well  built,  that  its  vulner- 
able parts  must  be  of  the  highest  order  of  efficiency — such,  for  instance,  as  the 
finger  of  the  interlocking  device  on  the  doors  and  the  hinge  and  hinge  rods.  In 
most  of  the  dressing  sterilizers  in  which  the  doors  open  outward  repairs  must  be 
done  so  frequently  that  the  apparatus  is  out  of  use  a  good  part  of  the  time;  these 
doors  are  heavy,  and  they  are  opened  and  closed  frequently,  and  thus  the  hinges  and 
hinge  rods  are  subjected  to  a  great  deal  of  wear  and  tear,  to  say  nothing  of  their 
share  of  the  pressure  from  within.     This  wear  and  tear  on  the  doors  has  the  effect 


Fig.  76. — Bramhall  autoclave. 


STERILIZERS    M>K    INSTITUTION    I  SE 


171 


of  loosening  the  seat  in  most  of  the  sterilizers,  which  tends  to  decrease  the  efficiency 
by  releasing  a  certain  amount  of  the  steam. 

In  the  Michael  Reese  Hospital  a  careful  test  has  been  made  recently  of  the  ad- 
vantages and  disadvantages  between  the  American  dressing  sterilizer  and  one  of  the 
older  types,  and  it  was  found  that,  in  addition  to  the  advantages  of  the  safetj 
device  and  the  greater  durability  of  the  hinge  and  bearing  parts,  the  American 
apparatus  has  a  great  advantage  in  the  time  employed  in  bringing  it  up  to  the 

.        I 


Fig.  77. — "American"  dressing  sterilizer,  including  independent  steam  generator  with 
automatic  control  valve  and  the  "  American  "  (patented'  three-way  control  valve,  by  means  of 
which  steam  is  admitted  to  chamber,  withdrawn  from  chamber,  and  vacuum  created  in  chamber 
at  the  will  of  operator. 

proper  steam  pressure.  The  American  sterilizer  (Fig.  77),  used  was  21  inches  deep 
and  22  inches  in  diameter,  inside  measurement,  and  it  was  found  that  250°  F.  of 
heat  (that  is  15  pounds  of  pressure)  could  be  reached  in  three  minutes,  which  is 
about  ten  times  as  rapid  of  operation  as  the  other  machine,  a  very  considerable 
point  in  a  busy  operating  department.  This  is  due  to  the  independent  steam  gen- 
erator. Additional  security  is  offered  in  the  door  of  this  sterilizer  by  a  stop  notch 
in  the  wheel  screw,  which  releases  the  door  so  it  gapes  a  quarter  of  an  inch,  sufficient 


172 


EQUIPMENT    OF   THE   HOSPITAL 


to  allow  any  unregistered  steam  to  escape  sideways,  and  holding  it  there  for  an 
instant  before  opening  completely  (Fig.  78) ;  this  saves  careless  nurses  from  being 
burned.  In  its  operation  this  sterilizer  acts  like  the  other  so-called  vacuum  devices, 
having  a  steam  jacket,  an  outer  and  an  inner  shell,  with  an  opening  at  the  depend- 
ent points  of  the  bottom,  by  which  air  is  forced  out  of  the  cylinder  as  the  steam 
enters  under  pressure,  and  mobilized  from  time  to  time,  so  that  it  will  have  an 
opportunity  to  invade  whatever  pockets  there  are. 

All  the  present  makes  of  dressing  sterilizers,  excepting  the  Bramhall  Dean,  are 
based  upon  principles  laid  down  in  the  old  Sprague  sterilizer  of  more  than  twenty 
years  ago,  and  no  improvement  whatever  has  been 
made  since   that  time,   except    in   the  matter   of 
material  and  finish. 

The  Hospital  Supply  Co.,  of  New  York,  is  the 
A\    n  lp\_|    \  \       \        first  manufacturing  concern  to  attempt  the  design 

I    ^  JMLj  \        J        0f  an  entirely  new  principle  in  dressing  sterilizers 

>U    U  InlN-Jl  /       >       — that   is,    a  new   design   for    this    country.      In 

Europe,  especially  in  Germany,  the  cabinet  or  wall 
sterilizer  has  been  in  use  for  some  years;  not  a 
wholly  satisfactory  use  it  is  true,  but  along  lines 
that  the  Hospital  Supply  Co.  seem  to  think  they 
can  make  perfectly  efficient  by  certain  changes  de- 
vised in  the  Michael  Reese  Hospital  for  this  mechan- 
ism. This  new  cabinet  sterilizer  is  only  18  inches 
deep,  set  into  the  wall  or  recess,  and  properly  in- 
sulated by  asbestos  composition.  The  door  is 
copper-lined,  with  a  layer  of  asbestos  composition 
between  the  outer  and  inner  plates,  so  that  the 
radiation  of  heat  is  reduced  to  a  minimum.  Any 
number  of  drums  or  metal  dressing  boxes  can  be 
placed  in  the  shelves  and  kept  there  after  steriliza- 
tion, as  in  an  ordinary  cabinet,  or  sealed  and  set  in 
the  drum  racks. 
This  cabinet  has  the  advantage  of  the  present  dressing  sterilizer,  and  yet  occu- 
pies no  much-needed  space  about  the  operating-rooms,  and  has  practically  no 
heat  radiation.  There  is  a  packing  of  magnesium  blocks  for  non-radiation  surround- 
ing the  cabinet  except  on  the  front  or  door  side. 

While  we  are  on  the  subject  of  dressing  sterilizers,  it  will  not  be  inappropriate 
to  say  a  word  on  the  desirability  of  sterilizing  operating  clothing,  bandages,  packs, 
and  sponges  in  a  container  that  can  be  subsequently  sealed  and  kept  sterile  until 
used.  These  sterile  drums  are  12  inches  in  diameter  and  9  or  12  inches  high. 
The  lid  is  fastened  with  staple  and  hasp,  and  can  be  locked  for  perfect  security. 
Around  both  top  and  bottom  of  the  sterilizer  is  a  broad  rim  1  inch  in  width,  with 
|-inch  holes  at  intervals  of  2  inches,  and  there  are  corresponding  holes  underneath 
in  the  body  of  the  drum,  which  are  opened  or  closed  by  sliding  the  bands.  Another 
type  contains  elliptical  holes  at  intervals  all  over  the  sides,  with  wire-mesh  cover- 
ing, and  inner  slide  device  for  covering  the  holes  after  sterilization.  The  objection 
to  this  form  is  that  the  great  amount  of  surface  covered  in  the  double  jacket  per- 
mits the  whole  mechanism  to  get  out  of  working  order  if  a  small  dent  is  made  at 
any  point. 

After  the  drums  have  been  packed  the  holes  are  opened,  and  they  are  closed 
immediately  after  the  drums  are  taken  from  the  sterilizer. 


Fig.  78. — Cross-section  of 
"American"  dressing  sterilizer. 
Door  construction,  including 
packing  joint,  ball-and-socket 
arm  connection,  and  improved 
stop. 


STERILIZERS    FOR    INSTITUTION    USE  173 

Under  the  head  of  Operating-room  Material,  in  another  part  of  the  hook,  will 
be  found  a  list  of  the  packages  usually  contained  in  these  drums,  and,  if  used 
properly,  the  whole  device  is  most  satisfactory.  There  can  he  a  sufficient  number 
of  drums  to  meet  any  emergencies  in  the  operating-rooms,  and  the  drums  can  be 
so  packed  that  they  will  answer  for  the  usual  classic  operations. 

Water  Sterilizers. — Most  hospitals  have  a  water-sterilizing  attachment  to  the 
general  power  plant,  and  all  the  water  t  hat  runs  to  the  operating-  and  dressing- 
rooms  is  sterilized,  and,  in  most  of  these  plants,  the  sterilized  water  has  been 
previously  triple  filtered,  to  take  out  the  mechanical  dirt. 

In  connection  with  one  such  institution,  where  the  power  plant  was  located  at 
the  end  of  350  feet  of  water  pipe  before  it  reached  the  operating-room,  repeated 
tests  of  the  sterilization  were  made,  and,  notwithstanding  the  fact  that  medical 
men  believe  water  pipes  are  liable  to  bacterial  growths,  every  test  showed  the  water 
to  be  sterile.  Nevertheless,  most  surgeons  seriously  object  to  the  use  of  such  water 
fur  t  lie  irrigation  of  wounds  and  for  wringing  sponges,  as  well  as  for  the  making  up 
of  their  solutions,  so  that  additional  precautions  must  be  taken,  and  this  must  be 
done  by  the  use  of  water  sterilizers  in  the  operating-rooms. 

All  the  commercial  water  sterilizers  offered  on  the  market  to-day  are  capable 
of  giving  practically  a  perfect  sterilization  to  meet  the  most  exacting  requirements 
for  operating-  and  dressing-rooms.  These  sterilizers  are  made  up  of  three  parts — 
a  quartz  filter,  through  which  the  water  to  be  used  is  passed  as  it  enters  the  chamber, 
a  jacket  containing  the  live-steam  pipes,  and  the  container  itself.  Up  to  this 
point  all  the  sterilizers  are  practically  the  same.  There  is  one  point,  however, 
well  worthy  of  consideration,  and  that  is  the  question  of  the  ease  with  which  the 
water  sterilizer  can  be  cleaned.  Nearly  all  these  sterilizers  are  built  with  the  tank 
ami  its  bottom  in  one  piece,  with  a  top  removable  by  means  of  bolts.  This  seems 
to  be  an  error  of  construction,  since  it  is  practically  impossible  to  keep  out  every 
particle  of  mechanical  dirt,  even  after  careful  filtration,  and  this  dirt  will  gravitate 
to  the  bottom.  In  the  course  of  time  quite  a  layer  of  dirt  will  lie  on  the  bottom  of 
the  sterilizer,  and  there  ought  to  be  a  means  of  reaching  the  bottom  for  cleaning 
purposes.  In  only  one  of  the  sterilizers  made  is  this  point  covered,  and  that  is  in 
the  mechanism  offered  for  sale  by  the  American  Sterilizer  Co.  In  this  mechanism, 
as  shown  in  Fig.  79,  the  sterilizer  itself  is  shown  as  a  one-piece  device,  except- 
ing for  the  bottom,  which  is  bolted,  making  the  sterilizer  easily  accessible  for 
cleaning  purposes.  The  bolts  are  hidden  on  the  inside  of  the  rim;  the  top  being 
a  part  of  the  shell,  it  is  smooth  and  easily  kept  clean  on  the  outside,  and.  as 
the  whole  shell  lifts  up  with  a  moment's  work,  the  mechanism  is  easily  cleaned 
of  sediment. 

The  other  makers  claim  that  their  apparatus  is  quite  as  easily  cleaned  by  tak- 
ing the  bolts  out  of  the  top  lid  and  lifting  out  the  coils.  But  the  sediment  is  still 
at  the  bottom,  and  the  whole  mechanism  must  be  dismantled  to  get  at  it. 

Recently  a  new  plumbing  arrangement  has  been  designed  for  obtaining  hot  or 
cold  sterile  water  from  the  sterilizers,  delivered  to  the  sinks  in  the  operating-rooms 
by  means  of  piping  and  faucets.  This  mechanism  contemplates  placing  the  hot-  and 
cold-water  sterilizers  at  the  ceiling  in  the  sterilizing  room,  piping  over  to  the  one 
or  more  sinks  in  the  operating-room  proper,  so  that  hot  or  cold  water  can  he  drawn 
at  the  sink  just  the  same  as  other  water.  Additional  faucets,  self-closing  in  type, 
must  be  placed  over  the  sink  in  addition  to  those  for  ordinary  washing  water. 
Heretofore  sterile  water  has  been  carried  usually  in  pitchers,  and,  more  often 
still,  the  ordinary  water  that  has  come  from  the  power  plant,  or  from  the 
city  mains,  has  been  used  for  the  irrigation  of  wounds,  dipping  of  sponges,  and 


174 


EQUIPMENT    OF    THE    HOSPITAL 


so  on.  Most  surgeons  are  no  longer  satisfied  with  this  slip-shod  method,  and 
demand  not  only  sterile  water,  but  demand  that  it  be  sterilized  in  the  operating- 
room  suite. 

Instrument  Sterilizers. — There  is  almost  no  point  to  be  made  concerning  instru- 
ment sterilizers  for  operating-rooms;  any  metal  box,  mounted  Upon  legs  to  give  a 
convenient  height,  is  practical  for  all  purposes  of  instrument  sterilization.     The 


Fig.  79. — "American"  design  of  water  sterilizers  with  all  operating  valves  (each  fitted  with 
name-plate  indicating  function)  and  self-contained  piping.  These  reservoirs  are  also  fitted  with 
our  new  design  of  quick  closing  water-gage  valves;  separating  joint  for  cleaning  at  bottom, 
thus  giving  direct  access  to  the  interior  and  doing  away  with  the  unsightly  dust-catching  joint 
at  top. 

instruments  are  set  in  a  tray  and  covered  with  a  towel,  and  the  sterilizer  is  partly 
filled  with  hot  water  and  live  steam  is  turned  in.  This  is  the  simplest  form  of 
sterilization,  because  there  are  no  hiding  places  for  micro-organisms,  and  uniform 
wet  heat  can  reach  every  part  of  the  instruments  at  all  times.  The  only  point  about 
instrument  sterilizers  is  that  they  must  be  operated  by  a  foot  pedal,  since  nearly 
always  the  nurse  who  handles  the  instruments  is  a  clean  nurse,  and  oftentimes 


STERILIZERS    FOR    INSTITUTION    USE 


175 


she  is  gloved  for  clean  work.  A  mechanism  that  will  raise  the  tray  to  the  top 
is  desirable,  because  a  nurse  working  in  a  hurry  will  sometimes  burn  herself 
lifting  a  tray  out. 


Fig.  80. — "American"  special  combination  sterilizing  outfit,  consisting  of  dressing,  water 
and  utensil,  and  instrument  sterilizers,  together  with  six  water-tight  storage  lockers,  designed 
expressly  for  U.  S.  Navy  Department,  and  installed  on  battleships  "Arkansas"  and  "Wyom- 
ing." 


Combination  Set. — Figure  80  shows  a  compact  set,  made  up  of  all  the  neces- 
sary units — dressing  utensil,  water,  and  instrument.  This  is  a  most  convenient 
set  for  small  hospitals.  It  can  be  had  to  run  by  electricity  where  high-pressure 
steam  is  not  available,  or  by  a  small  gas  boiler.     The  set  costs  about  $400. 


FURNITURE  IN  THE  HOSPITAL 

Beds  and  bed  fittings,  tables  of  various  sorts,  chairs,  receptacles  for  clothing, 
and  rugs  for  the  floors — all  these  are  furniture  common  to  all  parts  of  any  insti- 
tution, and  it  may  be  just  as  well  to  take  them  up  in  their  regular  order  in  this  place. 

BEDS 

The  bed  is  the  most  important  article  of  furniture  in  any  sick  room,  and  its 
composition  and  dressings  are  certainly  among  the  most  important  items  in  insti- 
tution administration.  Of  course,  none  but  metal  beds  are  to  be  considered.  It 
is  to  be  doubted  whether  the  particular  metal  makes  very  much  difference,  except 
as  a  matter  of  strength.  Simplicity  is  of  prime  importance,  because  plain  material 
can  be  cleaned  more  readily  and  will  be  cleaned  oftener  than  decorated,  fretted 
stuff,  and  white  enamel  is  the  best  material  to  clean,  because  it  shows  dirt  more 
readily,  and  will  therefore  be  cleaned  more  thoroughly;  but,  up  to  the  present 
time,  there  is  no  enamel  that  will  not  scratch  off  under  ordinary  usage,  and  nothing 
looks  quite  so  untidy  as  a  badly  scratched  white  bed.  White  enamel  again  makes 
the  cheapest  of  beds,  because  the  manufacturers  can  use  the  cheapest  forms  of 
iron  when  they  know  they  are  to  be  covered  by  a  white  paint.  For  the  wards  of 
an  institution  there  is  no  form  of  bed  now  made  that  will  take  the  place  of  white 
enamel,  but  we  must  resign  ourselves  to  the  fact  that  constant  re-enameling  must 
be  done. 

If  users  would  pay  the  price  for  a  properly  made  article,  bed  makers  would  be 
compelled  to  build  their  baking  ovens  large  enough  to  take  in  bed  parts,  and  take 
them  at  a  sufficiently  high  temperature  to  fuse  the  enamel  into  the  metal,  and  there 
would  be  no  cracking  or  scratching. 

For  private  rooms  brass  would  be  without  question  the  best  metal  for  beds, 
but  for  the  one  fact  that  at  the  present  time  no  polish  or  material  of  any  kind  is 
made  that  can  be  used  to  keep  the  brass  from  tarnishing,  and,  after  a  year  or  two 
of  wear,  with  the  spilling  of  acids  and  medicines,  brass  beads  are  not  pretty. 

The  design  of  the  hospital  bed  is  a  question  to  which  very  much  attention  has 
been  given  by  recent  inventors  and  designers,  and  there  is  on  every  hand  an  ap- 
parent desire  to  complicate  this  piece  of  furniture  by  the  addition  of  all  sorts  of 
alleged  conveniences.  They  are  made  now  so  that  the  feet  can  be  raised  and  the 
head  lowered,  or  vice  versa;  so  that  both  head  and  feet  can  be  raised  and  the 
buttocks  rested  in  a  hollow  between  the  two;  some  are  made  to  allow  patients  to 
sit  up  in  comfort,  and  some  are  even  made  so  that  they  can  be  tilted  sideways,  and 
patients  are  thus  allowed  to  turn  over  without  any  effort  on  their  part.  All  these 
efforts  are  worthy  as  to  their  intention,  but  result  in  complications  of  mechanism 
that  get  out  of  order  constantly,  are  veritable  dust  catchers,  and  almost  require 
an  engineer  to  operate  them. 

The  better  way  is  to  have  the  bed  in  the  simplest  possible  form,  and  pieces  of 
furniture  in  convenient  closets  about  the  ward  or  floor  that  may  be  used  for  achiev- 
ing the  same  purposes  intended  in  these  beds.  There  are  so  few  patients  that  need 
the  auxiliaries  that  it  seems  hardly  worth  while  to  furnish  a  hospital  with  a  lot  of 


11  KX  III  RE    l\   THE    HOSPITAL 


177 


lumbering  stuff  that  has  many  disadvantages  and  such  semi-occasional  usefulness. 
For  instance,  there  are  side  rests  made  of  wire,  and  bound  with  heavy  metal,  that 
arc  convenient  and  easily  placed  either  over  or  under  the  mattress.  There  are 
hack  rests  that  are  the  essence  of  simplicity  in  construction,  and  there  are  foot  props 
that  will  serve  every  purpose  to  prevent  patients  from  working  to  the  foot  of  the 
bed. 

The  height  of  the  bed  is  of  the  utmost  importance,  not  so  much  in  the  interest 
of  the  patient  perhaps  as  to  facilitate  easy  handling  by  the  nurse,  a  matter  that  is  of 
vital  importance  if  patients  are  to  obtain  adequate  care.  The  low  bed  is  a,  back- 
breaker.  The  low  bed  is  one  that  is  22  inches  to  the  top  angle  iron  frame  of  the 
mattress.  The  high  bed,  approximately  28  inches  high  to  the  top  of  the  mattress, 
will  never  lie  found  disagreeable  to  the  patient  while  lying  in  lied,  and  will  allow  the 
nurse  to  perform  all  the  necessary  duties  to  the  patient  without  stooping  over  much. 
The  high  bed  is,  of  course,  an  inconvenience  for  getting  in  and  out,  but  patients 


Fig.  SI. — High  bed  with  nurse's  couch  half  drawn  out. 

are  not  getting  out  and  in  bed  vcy  often,  and  the  act  of  assisting  them  in  and  out 
will  happen  infrequently,  while  die  duties  of  a  nurse  to  a  patient  lying  down  are 
so  constant  that  there  seems  tj  be  hardly  an  argument  against  the  high  lied. 

The  high  bed  is  especially  advantageous  in  private  rooms,  because  the  nurse's 
couch  can  be  kept  under  it  when  not  in  use,  and  oftentimes  these  couches  are  most 
grateful  to  patients  who  wish  to  change  for  a  rest  from  one  bed  to  another,  or  to 
allow  their  own  bed  to  air.  Figure  81  shows  a  high  bed  with  nurse's  couch  half 
drawn  out. 

Width  of  Beds. — The  width  of  the  bed,  especially  for  the  adult,  is  a  matter  of 
a  good  deal  of  importance.  The  patient  needs  a  wide  bed,  and  the  nurse  is  better 
off  if  the  bed  is  narrow,  but  as  the  patient  is  of  somewhat  more  importance,  and 
has  to  use  the  bed  more  constantly  than  the  nurse,  perhaps  we  would  better  con- 
sult the  patient's  comfort  rather  than  that  of  the  nurse  in  this  particular  instance; 
hence,  the  wider  the  bed  the  better  off  we  are.     Perhaps  a  happy  medium,  taking 


178 


EQUIPMENT    OF    THE    HOSPITAL 


into  consideration  the  patient's  comfort,  the  space  allowable,  and  the  ease  with 
which  the  patient  may  be  handled  by  the  nurse,  would  be  42  inches. 

Springs. — The  spring  of  the  bed  is  a  matter  of  very  great  moment,  so  far  as 
the  patient's  comfort  is  concerned,  durability,  and  economy.  Commercially,  the 
bed-spring  business  is  not  in  very  good  shape.  Figure  82  shows  one  that  is  perhaps, 
for  all  purposes,  the  best.  It  consists  of  chain  and  cross-chain  lengths,  with  wire 
side  line  from  end  to  end  of  the  bed,  and  with  spirals  at  each  end  of  every  chain. 
The  only  part  to  wear  out  with  this  spring  is  the  spiral,  especially  those  toward  the 
center  of  the  bed,  and  these  are  sometimes  made  of  double  strength,  so  that  the 
full  weight  of  the  patient  is  compensated  by  the  extra  strength  of  the  spring. 
This  spring  is  not  at  all  likely  to  give  down  in  the  middle,  it  does  not  fix  itself  in  a 
hollow,  and  gives  readily  with  the  movement  of  the  patient  from  side  to  side  or 
from  head  to  foot.  It  is  not  a  costly  spring.  It  can  be  used  in  private  rooms,  pri- 
vate and  public  w7ards,  in  the  adults'  or  childrens'  departments,  with  equal  comfort 


Fig.  82. — Form  of  bed  springs. 

and  advantage.  The  old  form  of  spiral  spring  is  out  of  date,  and  is  not  admissible 
for  the  purposes  of  a  public  institution.  It  hat  the  habit  of  wearing  down  in  the 
middle,  by  the  stretching  of  the  spirals. 

There  is  a  disposition  on  the  part  of  some  institution  managers  to  do  away 
entirely  with  springs,  and  to  use  slats  lengthwise  and  crossways,  made  of  metal 
bands.  When  this  is  done  there  must  of  course  be  a  very  large,  thick  mattress, 
and  it  may  be  doubted  whether  any  material  will  retain  its  springiness  sufficiently 
to  compensate  for  a  spring  of  a  different  sort  so  that  the  patient  will  be  comfortable. 

There  is  a  disposition  in  other  quarters  to  go  back  to  the  old  box-spring  of  twenty 
or  thirty  years  ago.  This  is  entirely  out  of  the  question,  because  the  box-spring 
can  never  be  cleaned,  and  becomes  a  breeding  ground  and  hiding  place  for  germs 
of  all  sorts,  microscopic  as  well  as  macroscopic. 

Mattresses. — The  mattress  is  perhaps  quite  as  important  as  the  spring,  and,  so 
far  as  the  comfort  of  the  patient  is  concerned,  much  more  important  than  any  of 
the  articles  in  the  furnishing  of  a  room. 


FURNITURE    IN   THE    HOSPITAL  179 

Some  of  thorn  arc  cotton,  some  felt,  some  a  mixture  of  these  two,  and  others 
of  h:iir  of  various  qualities  and  of  various  kinds.  It  is  questionable  whether  such 
a  mattress  as  the  Ostermoor  is  the  best  for  a  private  home,  and  for  well  people  to 
sleep  on,  but  the  manufacturers  of  these  fell  mattresses  have  not  striven  very  hard 
to  place  them  in  institutions,  for  the  obvious  reason  that  they  do  not  lend  themselves 
to  institution  requirements.  Beside  the  item  of  comfort  to  the  patient  that  of 
cleanliness  is  a  most  important  factor,  and  it  is  not  easy  to  get  blood  and  the  fluid 
secretions  out  of  a  felt  mattress.  The  same  would  be  true  of  cotton,  only  in  a 
greater  degree,  and  both  of  these  materials  should  be  ruled  out  for  hospital  beds, 
not  only  because  they  are  difficult  to  clean,  but  because  they  do  not  lend  themselves 
well  to  fumigation  and  sterilization,  on  account  of  the  compactness  of  their  texture; 
and,  notwithstanding  the  slightly  greater  first  cost,  there  is  no  material  for  the 
hospital  mattress  that  will  take  the  place  of  curled  hair.  It  is  expensive,  and  will 
cost  for  the  average  mattress  S8  to  $10,  but,  because  of  its  porosity,  it  can  be  easily 
fumigated,  and  under  the  severest  tests  the  hardiest  of  the  pathogenic  micro-or- 
ganisms can  be  destroyed  if  embedded  in  the  middle  of  a  thick  curled-hair  mattress, 
under  the  intense  fumigation  or  sterilization  that  will  be  employed  in  the  insti- 
tution. If  the  tick  is  soaked  with  blood  it  can  be  renewed,  and  the  hair  washed  and 
sterilized  at  a  total  expense  of  $1  or  SI. 50.  Then,  again,  curled  hair  is  a  versatile 
mattress  in  its  usefulness;  it  can  be  made  into  pads  of  any  size  and  thickness  and 
for  any  purpose,  either  for  adults  or  infants.  Pillows  can  also  be  made  out  of  it 
for  leg  or  arm  rests.  It  does  not  wear  out,  and  is  practically  a  permanent  invest- 
ment. If  desirable,  it  can  be  turned  out  in  bulk  into  the  fumigating  room  and 
fumigated,  or  disinfected  at  any  temperature  required,  even  to  the  point  of  live 
steam. 

The  cheaper  grades  of  hair  are  not  economic  because  the  individual  hairs 
break,  and  eventually  the  mattress  packs  like  felt  without  the  latter 's  springiness; 
the  hair  is  too  short  in  these  cheap  grades. 

Childrens'  Beds. — There  are  so  many  points  to  be  considered  in  the  design  and 
use  of  a  child's  bed,  and  so  many  conditions  to  meet  as  to  the  place  in  which  the 
bed  is  to  be  used,  the  age  of  the  child  for  whom  it  is  intended,  whether  it  is  a  well 
child  or  a  sick  child,  that  there  seems  not  to  have  been  designed  any  bed  that 
would  meet  all  the  required  conditions.  First,  we  must  think  of  the  very  small 
infant,  only  recently  born  perhaps,  whose  mother  is  not  yet  strong  enough  to  lift 
the  child  over  a  high  rail.  Then,  for  this  same  young  baby  the  bed  must  be  made 
with  bars  so  close  together  that  the  head,  or  even  a  limb,  cannot  get  through  so 
as  to  be  hurt  in  case  the  child  tosses  about.  Then,  there  is  the  older  child,  just 
learning  to  stand  while  holding  on  to  something,  and  that  will  certainly  pitch  over 
t lie  top  of  a  rail  unless  it  is  higher  than  the  rails  of  most  beds.  If  we  are  to  have  a 
rail  around  a  child's  bed,  the  catches  must  be  so  strong  and  easily  adjustable  that 
there  will  be  no  danger  of  the  child  pushing  the  rail  over,  in  the  event  that  the 
nurse  or  mother  should  happen  not  to  latch  it  securely.  There  is  also  the  still 
larger  child  that  rolls  about  and  tosses  in  bed.  These  conditions  concern  the  age 
of  the  child. 

Now,  let  us  take  the  private  home,  in  which  there  cannot  always  be  a  nursery 
maid,  and  where  the  mother  must  depend  upon  some  sort  of  security  after  it  has 
reached  the  crawling  age,  and  where  it  cannot  get  hurt.  We  oftentimes  see  two 
or  three  chairs  laid  down  on  the  floor,  and  a  pen  made  of  them  to  keep  the  child 
from  crawling  into  danger,  but  nearly  always  there  are  openings  through  the  parts 
of  the  chair  that  the  baby  will  crawl  through,  and  perhaps  gel  into  the  tire  or  fall 
downstairs;  or  perhaps  the  baby  may  pull  one  of  these  chair-  over  on  itself  and  be 


180 


EQUIPMENT    OF    THE    HOSPITAL 


severely  hurt;  then  there  are  nearly  always  rough  parts  of  the  chair  exposed,  so 
that  the  baby  may  fall  and  be  severely  injured.  But  the  baby  that  is  old  enough 
to  get  into  this  sort  of  michief  will  be  old  enough  also  to  climb  over  the  rail  of  almost 
any  of  the  ordinary  makes  of  bed  and  fall  to  the  floor,  so  that  it  seems  we  need  a  bed 
with  a  rail  high  enough  so  that  the  baby  can  play  in  it,  and  allow  the  mother  to  be 
in  another  room  or  downstairs,  without  any  fear  of  something  happening. 

We  must  always  think,  too,  of  a  rail  for  the  child's  bed  that  can  be  almost  auto- 
matically so  securely  fastened  that  there  will  be  no  danger  of  a  careless  nurse  or  a 
careless  mother  leaving  it  in  such  shape  that  the  child  will  push  it  down. 

Then,  there  is  the  hospital  bed;  and  this  bed,  too,  must  meet  a  number  of  re- 
quirements, all  those  that  have  been  suggested  above,  and  others  made  necessary 


Fig.  83. — Child's  bed  designed  by  the  author — cage  lowered. 

by  the  large  number  of  children  that  a  single  nurse  must  sometimes  care  for,  that 
is,  the  security  must  be  even  greater  than  in  a  case  of  a  single  child  in  its  own  home. 
The  child's  bed  in  the  hospital  must  be  of  a  sufficient  size  and  of  proper  make  so 
that  either  a  very  young  baby  or  a  child  of  considerable  size  can  be  accommodated 
in  it.  There  is  the  question  of  space  in  the  ward  that  must  be  taken  into  con- 
sideration. The  children  s'  ward  in  the  hospital  is  usually  made  up  of  rows  of  beds, 
with  the  heads  against  the  wall,  and  in  this  modern  day  it  is  a  prerequisite  that 
every  child  shall  have  its  own  equipment,  linens,  dishes,  dressings,  thermometer, 
and  the  like,  and  these  may  be  kept  on  a  small  table  at  the  bedside.  So  we  have 
a  large  number  of  varying  conditions  that  confront  us  when  we  attempt  the  selec- 
tion or  design  of  a  child's  bed.  Take,  for  instance,  the  hospital  child's  bed  in 
which  the  rail  is  fastened  to  each  end  at  the  top  with  a  bolt  that  goes  into  the 


KrHXITlKK    IN    THK    HOSPITAL 


181 


upright,  when  the  bolts  arc  drawn  out  the  rail  falls  outward  and  downward.  This 
makes  it  necessary  that  we  shall  have  an  unoccupied  space  on  each  side  of  the  bed 
equal  to  the  height  of  the  rail,  so  that  the  rail  will  not  be  impeded  when  it  is  swung 
outward  and  downward;  even  if  we  have  a  sufficient  unoccupied  space  to  allow  of 
the  rail  being  swung  downward  on  either  side,  we  will  sometimes  have  tin-  attend- 
ing physician  and  the  intern  walking  up  to  the  bed  on  one  side  for  the  purpose  of 
examining  the  child,  and  the  nurse  will  be  on  the  other  side,  and  it  will  lie  a  very 
awkward  matter  for  the  nurse  to  lower  the  rail  on  the  doctor's  side  without  neces- 
sitating the  doctor's  getting  out  of  the  way,  and  time  will  be  required  for  the  nurse 
to  go  round  on  her  side  and  lower  her  own  rail  so  she  can  undress  the  child. 
The  bed  with  the  outward  swinging  rail,  one  on  each  side,  is  one  of  three  forms  of 
child's  bed  that  can  be  purchased  on  the  market. 


Fig.  84.— Cr 


by  the  author — cage  raised. 


The  second  style  is  one  in  which  the  side  rails  travel  straight  tip  and  down  on  an 
independent  rod,  with  a  hook  catch  at  the  top  of  each  end  that  catches  on  a  pro- 
jecting notch.  The  objection  to  this  style  of  bed  is  that  it  requires  almost  no  force 
to  spring  the  rod  at  one  end  or  the  other,  so  that  the  rail  will  bind  as  it  passes  up 
and  down;  and  it  is  the  experience  of  hospital  people  that  this  rod  is  nearly  always 
so  out  of  order  that  the  rail  does  not  work  freely.  Another  objection  to  this  bed 
is  that  tin1  catches  oftentimes  stick  and  fail  to  clasp  the  projecting  notch  firmly 
enough  to  insure  that  the  rail  will  not  fall.  Many  accidents  have  happened  to 
children  on  account  of  this  rail  slipping  from  its  fastening  and  catching  the  leg 
or  arm  or  head  of  the  child. 

There  is  another  style  of  bed  not  so  well  known  as  the  two  above;  this  is  a  fixed 


182 


EQUIPMENT    OF   THE    HOSPITAL 


cage  fastened  to  four  posts,  and  the  two  longitudinal  side  rails  of  the  bed  project 
considerably  beyond  the  head  and  beyond  the  foot.  The  ends  of  these  two  rails 
are  movable  pieces  fastened  with  a  spring,  and  on  the  inside  of  the  two  upright 
posts  are  notches  in  which  these  extensions  can  be  made  to  catch.  The  bed  is 
worked  by  one  nurse  at  each  end.  The  two  extensions  are  pulled  toward  each  other 
out  of  the  notches,  and  the  bed  containing  the  child  is  raised  or  lowered  to  the  desired 
point,  and  the  extensions  are  then  released  so  that  the  bed  catches  at  that  height. 
The  objection  to  this  bed  is  that  it  must  be  pulled  away  from  the  wall  in  order  to 
be  worked,  and  that  it  requires  two  nurses  to  work  it.  It  was  designed  by  Dr. 
Holt  for  the  New  York  Babies'  Hospital. 

There  is  a  new  form  of  child's  bed,  designed  by  the  author,  and  intended  to 
overcome  all  of  the  objections  of  all  the  other  beds.  Figures  83  and  84  show  two 
views  of  this  bed.    It  consists  of  four  posts,  30  inches  high.    These  posts  are  held  in 


Fig.  85. — Nurse's  couch. 

place  by  an  angle-bar  running  entirely  around  the  top,  and  a  second  one  running 
around  the  lower  part,  about  6  inches  above  the  floor.  The  spring  of  the  bed  is 
stretched  across  the  top  bar.  The  posts  are  slotted  on  the  inside.  The  rail  of  the 
bed,  26  inches  high,  extends  clear  around,  and  each  corner  contains  a  guide  runner 
that  works  up  and  down  in  the  slot  of  the  post.  This  arrangement  allows  the  cage 
to  play  up  and  down  the  posts.  Across  the  bed  in  the  middle,  and  just  under  the 
spring,  is  a  spring  roller,  to  act  precisely  as  an  ordinary  window-shade  roller.  A 
steel  cable  runs  from  each  post,  to  wind  around  this  spring  roller,  and  is  fastened 
to  the  guide  runner  on  the  inside  of  the  post  over  a  small  pulley. 

This  arrangement  forms  a  spring  counterweight  for  the  cage,  so  that  one  may, 
with  a  single  finger,  raise  or  lower  the  cage  to  any  desired  height.  The  spring  is  so 
adjusted  that  the  cage  will  remain  where  it  is  placed,  whether  it  be  clear  down, 
giving  one  the  impression  that  the  bed  is  merely  an  examining  table,  or  at  its  full 


FURNITURE    IN    THE    HOSPITAL 


183 


height  of  21')  inches  above  the  mattress.  The  balance  of  the  mechanism  consists  in  a 
screw  lock  worked  from  either  side,  and  which,  when  given  half  a  turn,  locks  the 
cage  at  its  desired  height. 

This  lied,  though  rather  complicated  in  the  description,  is  extremely  simple, 
and  no  more  intricate  in  its  mechanism  than  the  ordinary  curtain  shade.  It  can 
be  made  quite  as  cheaply,  if  not  even  cheaper  than  the  other  child's  beds,  and  it  is 
believed  that  it  will  fill  a  definite  place  wherever  there  is  a  child. 

Interns'  and  Nurses'  Beds. — Living  accommodations  for  nurses  and  interns 
are  usually  limited,  and  there  is  nothing  more  comforting  to  the  young  people  after 
their  work  is  over  than  to  be  able  to  lounge  in  their  rooms.  Usually  their  quarters 
are  not  large  enough  to  afford  space  for  couches,  so  that  the  beds  must  be  made  to 
serve  for  lounging  as  well  as  for  sleeping  purposes,  so  that  it  is  well  to  remember 
two  or  three  things:  first,  the  beds  should  be  low  for  the  comfort  of  lounging;  next, 
they  ought  to  have  strong  springs,  very  much  stronger  than  will  be  necessary 
where  sick  people  are  to  occupy  the  beds,  because  these  young  people  oftentimes 
do  some  gymnastics  on  their  beds. 

Perhaps  the  nurse's  couch  shown  in  Fig.  85  will  be  best  for  their  rooms.  This 
couch  is  of  iron,  strongly  and  simply  made,  with  a  serviceable  spring.  It  is  com- 
fortable to  sleep  on,  easily  kept  clean,  and  occupies  less  room  than  any  other  bed. 

BED  RESTS 

There  are  a  number  of  pieces  of  mechanism  designed  to  give  the  patient  a  change 
of  position  in  bed.  The  most  important  of  these  is  the  back  rest.  This  is  a  simple 
mechanism,  as  shown  in  Fig.  86,  but  a  very  much-used  device  in  all  institutions 


Fip.  86. — Simplest  form  of  bed  rest. 

where  there  are  sick  people.  It  can  be  raised  or  lowered  by  the  simple  notched  arm, 
as  shown  in  the  cut,  so  that  a  patient  may  almost  lie  down  or  sit  almost  straight 
up.  The  body  of  the  device  is  of  wire  netting,  si)  that,  if  desired,  the  patient's 
back  can  be  exposed  to  the  air,  with  sheet  or  light  blanket  protection,  and  thus  the 
effects  of  the  hot  bed  can  be  ameliorated  for  the  time.  It  may  be  doubted  whether 
there  is  a  choice  in  the  several  makes  of  this  device.     They  all  serve  practically  the 


184 


EQUIPMENT    OF    THE    HOSPITAL 


same  purpose  in  practically  the  same  way,  and  as  the  only  opportunity  for  break- 
age is  in  rough  handling  when  being  moved  from  place  to  place  they  last  a  long 
time. 

There  is  another  form  of  device  employed  to  place  the  patient  on  the  side.  It 
extends  practically  from  the  shoulder  to  the  lower  hips,  and  the  patient's  body  rests 
in  the  mechanism  as  though  in  a  swing.  It  is  often  grateful  to  very  helpless  patients 
and  to  those  with  bed  sores,  and,  while  not  nearly  so  commonly  used  as  the  back 
rest,  one  or  two  should  be  kept  in  every  institution. 

Both  of  these  pieces  of  mechanism  will  work  entirely  independent  of  any  neces- 
sity to  have  a  specially  devised  bed,  cumbersome  and  complicated,  the  spring  of 
which  can  be  made  to  assume  any  one  of  half  a  dozen  positions,  either  to  ease  the 
patient  or  to  meet  the  requirements  of  the  attending  physician  or  surgeon. 

There  are,  of  course,  also  arm  rests  and  leg  rests  made  with  wire-mesh  work. 
These  are  rather  special  appliances,  and  are  a  matter  of  taste  and  special  occasion, 
rather  than  a  part  of  the  ordinary  equipment  of  an  institution. 


Fig.  87. — Greensfelder's  bed-splint. 


Fig.  88. — Greensfelder's  bed-splint. 


Buck's  extension  is  a  strictly  surgical  apparatus,  designed  by  a  surgeon  to  meet 
special  indications  in  fractures,  and  need  not  be  more  than  mentioned,  and  the 
same  is  true  of  the  many  modifications  of  the  Buck  mechanism.  The  Hodgen 
splint  for  leg  fractures,  and  for  injuries  to  dependant  parts  of  the  leg  or  thigh,  is  a 
very  old  and  a  very  useful  splint,  unfortunately  not  very  well  known  to  modern 
surgery.  There  is  a  new  bed  splint  for  children  that  seems  to  justify  more  than 
passing  mention.  Two  views  of  it  are  shown  in  Figs.  87  and  88.  It  was  designed 
by  Dr.  L.  A.  Greensfelder  for  the  children's  service  in  the  Michael  Reese  Hospital. 
Obviously,  it  is  intended  for  treatment  of  hip  fractures  in  children,  and  permits 
the  patient  much  freedom  of  movement,  either  in  bed  or  in  a  wheel  chair. 


BED  RAISERS 


The  bed  is  not  a  very  light  article  of  furniture,  and  the  leverage  that  must  be 
applied  to  raise  the  bed  is  considerable,  especially  with  the  ordinary  commercial 
bed  raisers,  that  must  be  partly  slipped  under  the  bed  in  half-horizontal  position, 
and  then  stood  upright  upon  fastenings  provided  for  the  purpose. 


Kl'UMTl'HK    IN    THE    HOSPITAL 


185 


Another  form  of  this  mechanism  is  represented  by  Fig.  89.  This  is  set  close 
to  tin'  head  or  Tool  of  the  bed,  whichever  it  is  designed  to  raise,  and  two  people  are 
required,  one  cm  either  side,  to  raise  the  bed  up  to  the  notches.  Usually  the 
people  who  raise  the  bed  raise  it  too  high  and  let  it  drop  into  place,  so  that,  in  the 
ease  of  either  of  these  devices,  there  must  be  a  considerable  amount  of  strength  to 
withstand  the  wear  and  tear  of  constant  usage.  Of  course  there  will  be  careful 
people  who  use  them  and  careless  people,  and  let  us  give  the  nurses  and  orderlies 
the  benefit,  of  the  doubt,  and  say  that  there  will  be  one  hundred  careful  people  who 
raise  the  beds  to  one  careless  one.  But  the  one  careless  one  will  break  a  hook  off, 
and  the  mechanism  is  rendered  useless,  because,  as  a  rule,  separate  parts  are  not 
made  for  this  mechanism,  the  design  of  all  those  offered  on  the  market  being  prac- 
tically the  same,  and  most  of  them  are  made  to  fit  any  form  of  bed.  In  purchasing 
this  device  we  look  for  two  things — strength  and  price. 


What  seems  to  be  the  most  practical  and  efficient  bed  raiser  now  offered  on  the 
market  is  made  by  the  Bernstein  Co.,  of  Philadelphia.  It  is  simply  a  large  caster, 
with  extension  that  fits  up  into  the  hollow  tubing  of  the  bed-post.  There  is  a  pin 
that  goes  through  the  tubing  and  the  extension.  One  nurse  raises  it  up  while  a 
second  nurse  removes  the  pins  and  resets  them  in  the  new  place.  Unfortunately, 
the  bed  has  to  be  made  with  a  view  to  this  particular  form  of  raiser. 


BED  ROLLERS 

Bed  rollers  are  made  to  wheel  the  bed  from  place  to  place  about,  the  ward,  or 
from  one  pari  of  the  hospital  to  another.  They  are  used  instead  of  the  bed  castors 
proper,  because  they  are  fitted  with  large  wheels,  rubber  or  pneumatic  tires,  ami 
move  noiselessly,  without  jolting  the  patient  and  without  marking  the  lloor.  The 
rollers  are  made  to  fit  the  ordinary  ward  beds,  and  the  process  of  applying  them  is 


186 


EQUIPMENT    OF   THE    HOSPITAL 


to  slide  the  wheels  part  way  under  the  bed  until  the  bottom  rod  of  the  bed  catches 
into  the  fastenings  made  for  the  purpose,  and  they  are  then  lifted  to  a  vertical  posi- 
tion. There  is  a  clamp  at  the  top,  on  each  side  of  the  roller,  as  shown  in  Fig.  90, 
that  holds  the  top  round  of  the  bed,  and  the  roller  becomes,  in  effect,  a  part  of  the 
furniture. 

Care  must  be  taken  in  this  roller  to  see  that  it  is  designed  to  fit  all  the  beds  in  the 
institution.  The  top  clamps  are  not  made  to  go  high  enough  to  fit  some  beds,  and 
the  bottom  clamps  often  do  not  reach  out  far  enough  to  catch  the  cross-bars  of 
other  makes.  These  rollers  are  usually  made  of  castings,  and  one  often  sees  a 
large  number  of  them  broken,  especially  the  hook  upon  which  the  bed  rests,  so  that 
special  care  must  be  taken  to  see  that  these  rest  pieces  are  strong  enough.  A  good 
many  of  these  makes  of  bed  rollers  are  fitted  with  a  heavy  piece  of  rubber  band  on 


Fig.  90.— Bed  rollers. 


the  wheels,  instead  of  cushion  tires,  and  when  they  are  new  they  run  very  smoothly 
and  noiselessly  and  do  not  jar  the  patient;  it  does  not  take  them  long,  however,  to 
dry  out,  become  loose,  and  they  eventually  crack  and  fall  off.  The  mechanism  is 
important  and  useful  enough  to  justify  a  better  tire  than  this,  and  a  form  of  bicycle 
tire,  with  grooved  rim  to  the  wheel,  is  not  very  much  more  costly  than  a  flat 
rubber  band.  Much  better  than  either  of  these,  however,  is  the  pneumatic  tire, 
practically  like  the  automobile  tire.  The  cut  shows  a  flat  tire,  which  is  by  no  means 
desirable. 

Some  designs  of  beds  do  not  lend  themselves  readily  to  the  ordinary  bed  roller 
and  bed  raiser.  Some  beds,  for  instance,  are  made  with  a  cross-bar  between  the 
two  head  posts,  6  inches  or  a  foot  from  the  floor,  and  this  bar  is  expected  to  hold 
the  weight  of  the  bed,  even  at  the  extreme  Fowler  position;  this  is  not  a  safe  way, 


FUUXITURP.    IN'    THF.    HOSPITAL 


187 


however;  in  brass  beds  this  bar  is  simply  a  piece  of  very  thin  brass  tailing,  fastened 

to  the  posts  by  small  screws,  and  it  is  unsafe  to  trust  the  weight  of  the  patient,  plus 
the  weight  of  the  bed,  to  these  bars  so  flimsily  fastened.  In  this  sort  of  bed  an  en- 
tirely different  arrangement  of  a  bed  raiser  and  bed  roller  must  be  substituted. 
In  some  institutions  the  raiser  or  roller  is  made  radically  different  for  this  reason — 
the  posts  of  the  bed  are  hollow,  and  the  casters  are  set  into  a  socket  in  the  bottom 
of  the  post.  Then  when  a  bed  roller  or  bed  raiser  is  to  be  used  the  caster  is  taken 
out,  and  the  raiser  or  roller  is  pushed  into  the  hollow  tube.  There  is  an  individual 
raiser  for  each  post,  and  there  is  a  stop  notch,  or  several  of  them,  to  gauge  the 
height  at  which  the  bed  is  to  be  held.     This  is  a  modification  of  the  Bernstein  castor. 


TABLES  IN  THE  INSTITUTION 

Ornamental  Tables. — There  must  be  tables  all  over  the  institution — in  recep- 
tion rooms,  study  halls,  libraries,  private  rooms,  and  wards,  and  they  ought  to 
be  ornamental    in    design,    yet    very    ^^^^^^^^^^^^^^^^^^^ 
simple    for    purposes    of    cleanliness.     | 
Some  of  them  must  be  of  wood,  and 
if  they  are  substantial  they  will  last 
longer   and  look    better  than   metal, 
and  give  an  air   of  luxury  wherever 
they  are.      It    is    the    style   now    to 
leave  ornamental  tables  free  of  cover- 
ing, except  perhaps  a  piece  of  drapery 
across  the  middle,  or  an  ornamental 
skin  thrown  with   artful   carelessness 
across  a  part  of  the  table  top.     Such 
tables  as  this    can   also  go  into  the 
rooms  of  the  nurses  and  interns  and 
the  well  people  of    the  hospital  gen- 
erally;   the    character    of    the    table, 
then,  depending  a  good  deal  on  the 
expenditure  possible. 

Bedside  Table. — Figure  91  shows 
a  bedside  table  that  seems  to  answer 
all  the  requirements.  It  is  easily  ad- 
justable as  to  height,  and  the  table 
part  can  be  set  at  any  angle.  It  may 
be  made  of  any  of  the  woods  or  of 
enamel.  The  top  may  be  made  any 
size  required.  It  may  be  made  with 
a  rim  around  the  edges,  so  that  china 
or  glassware  will  not  slip  off,  or  it  may 
be  made  with  the  top  entirely  plain, 
so  that  patients  may  use  it  conveni- 
ently for  writing  or  playing  cards. 

Side  Tables. — Each  room  and  each  ward  should  be  furnished  with  a  side  table, 
one  for  each  patient  occupying  the  room.  If  it  is  a  private  room,  something  like 
an  air  of  luxury  must  be  allowed;  therefore,  these  small  side  tables  should  be  of 
ornamental  wood,  harmonizing  with  the  other  furnishings  of  the  apartment. 
They  need  not  be  large,  perhaps  IS  by  20  inches  is  the  best  size,  with  a  drawer  in 


FiK.  91.— Bedside  tabic. 


188 


EQUIPMENT    OF    THE    HOSPITAL 


one  side,  and  with  a  shelf  8  inches  above  the  floor  on  which  to  place  books  and  mag- 
azines. Patients  in  private  rooms  like  to  cover  their  tables  with  friendly  fancy 
goods  brought  from  home. 

In  the  private  and  public  wards  it  is  not  possible  to  observe  the  same  amount  of 
individuality.  More  patients  use  the  tables,  and,  for  those  who  are  careless  of 
their  furniture,  it  would  seem  preferable  to  have  white  enamel  tables,  as  well  as  for 
their  durability  and  ease  of  cleaning  as  to  preserve  the  general  tidy  and  cleanly 
appearance  of  the  wards,  because  in  most  institutions  the  beds  and  screens,  and 
sometimes  the  dressers  and  chiffoniers,  are  made  of  white  enamel.  In  these  ward 
tables  the  material  of  the  top  is  of  some  consequence,  and  this  can  be  either  enam- 
eled, sheet  metal,  or  porcelain,  that  seems  to  be  coming  into  fashion  for  hospital 


Fig.  92. — Table  for  children's  ward. 

furniture.  Glass  is  not  advisable,  not  only  because  it  breaks  easily,  but  because 
things  slip  about  much  more  readily  on  glass  than  even  on  white  enameled  stuff. 
Childrens'  Bedside  Tables. — If  there  must  be  tables  in  the  childrens'  wards 
they  should  be  very  simple,  but  should  have  at  least  two  drawers  and  a  lower 
shelf  to  contain  a  drinking  glass,  mug  for  milk  or  other  drinks,  and  whatever 
nicknacks  a  child  may  be  allowed  to  eat  from  time  to  time,  such  as  oranges  or  crack- 
ers (Fig.  92).  In  the  first  drawer  are  the  dishes,  knife,  fork,  and  spoons,  cup  and 
saucer,  large  and  small  plate,  gruel  bowl,  and  perhaps  one  or  two  vegetable  dishes. 
In  the  lower  drawer  will  be  the  towels  and  linens  for  the  bed,  and  for  female  children 
of  whatever  age  there  should  be  vulval  pads,  made  of  some  material  cheap  enough 
to  be  destroyed  after  one  using.  They  are  making  now  a  very  handy  thermometer 
case,  nickel-plated,  with  small  chain  attached,  so  that  the  case  may  be  hung  to  the 


Fl'KNmKIO    I.\    THE    HOSPITAL 


189 


bed-post,  ami  these  cases  should  be  labeled,  one  for  the  mouth  and  one  for  the  rec- 
tum.    The  objection  to  them  is  that  the  patients  play  with  and  break  them. 


Fig.  93. — Head  nurse's  table. 


Fig.  94. — Metal  table  for  nurse's  station  and  history  sheet  holders. 


Of  course  the  linens  on  these  individual  tables  must  l>e  changed  daily,  and  they 
should  not  be  allowed  to  remain  in  the  ward  for  any  length  of  time,  as  there  is  eon- 


190  EQUIPMENT    OP   THE    HOSPITAL 

stant  danger  of  micro-organic  infections.  This  table  is  employed  in  the  contagious 
pavilion  of  the  Cook  County  (Chicago)  hospital. 

Serving  Tables. — The  only  other  tables  that  seem  to  be  of  sufficient  importance 
to  demand  special  consideration  are  the  serving  tables  in  various  parts  of  the  house, 
on  which  food  is  kept  and  from  which  it  is  served  either  to  patients,  patrons,  or 
employees,  and  the  only  detail  of  this  table  that  is  likely  to  cause  annoyance  is  the 
material  for  the  top.  It  is  almost  certain  that  linoleum  and  oil-cloth  must  be  re- 
jected, because  they  are  cut  too  frequently  in  the  slicing  of  bread.  If  it  is  a  figured 
linoleum  it  is  certain  to  be  scrubbed  with  sapolio,  which  will  wear  it  out  quickly. 
The  covering  of  zinc  is  expensive,  and  not  very  pretty  or  clean  looking,  and  it  is 
difficult  to  clean  a  zinc  top  so  that  it  will  not  look  greasy.  If  the  table  has  a  smooth 
top  of  fine-grained  wood,  and  there  is  very  much  wear  and  hard  use,  it  maybe  treated 
with  laboratory  stain,  the  formula  for  which  will  be  found  under  the  heading  of 
Equipment  for  the  Laboratory.  Grease,  acids,  alkalis,  and  the  like  will  not  effect 
this  stained  top,  and,  although  black  in  color,  it  will  always  look  clean. 

Head  Nurse's  Desk. — In  some  institutions  the  head  nurse's  quarters  are  in  the 
ward  itself,  and  sometimes  in  a  small  room  off  the  ward  or  corridor;  the  chief  article 
of  furniture  for  the  head  nurse  is  to  be  a  table,  and  on  the  character  of  this  will 
depend  the  system,  or  want  of  system,  with  which  the  head  nurse  does  her  work. 
Figure  93  shows  a  head  nurse's  table  that  seems  to  meet  the  requirements.  It  is  30 
to  36  inches  long,  18  inches  deep,  and  with  a  top  30  inches  high.  It  has  three  draw- 
ers, with  a.  shelf  above  the  top  drawer  and  just  under  the  table  top,  in  which  the 
record  books  may  be  kept.  The  three  drawers  may  be  broken  into  compartments  if 
desirable,  so  that  the  nurse  can  keep  things  well  separated.  This  table  is  of  white 
enameled  metal  ware  with  glass  top.  It  might  have  a  white  enameled  top  and  be 
quite  as  useful  and  ornamental.  It  should  by  all  means  be  fitted  with  rubber  tips 
on  the  feet.  On  top  of  the  table  or  over  it,  toggle  bolted  to  the  wall,  the  records 
may  be  kept  in  an  article  of  furniture  indicated  in  Fig.  94. 

CHAIRS  IN  THE  INSTITUTION 

There  is  probably  more  irresponsibility  in  a  hospital  than  in  almost  any  other 
occupied  building.  In  a  hotel  certain  servants  are  detailed  to  clean  certain  rooms, 
and  certain  dining-rooms  and  parlors,  and  if  furniture  is  broken  the  culprit  can  be 
easily  found.  In  a  hospital,  however,  there  may  be  a  dozen  or  twenty  different 
people  doing  things  in  a  single  room  or  ward  in  the  course  of  a  day — orderlies, 
nurses,  maids,  floor  men,  and  interns,  besides  the  patient  and  his  friends — and 
it  is  almost  impossible  to  fix  responsibility  for  the  breakage  of  furniture,  and  there 
is  more  wear  and  tear  on  the  chairs  than  any  other  of  the  furnishings.  People  insist 
on  sitting  on  the  arms  or  back,  or  tilted  back  with  two  feet  off  the  floor,  and  it  is 
probably  impossible  to  build  a  chair  that  will  not  break  if  a  heavy  man  tilts  back  in 
it  and  twists  it  about;  the  prime  consideration,  therefore,  in  the  chairs  of  an  insti- 
tution is  strength,  and  this  must  be  had  without  very  much  reference  to  the  pri- 
mary expenditure.  A  good  chair  may  cost  $6,  and  last  six  years,  whereas  a  poor 
chair  will  probably  cost  $4,  or  in  that  proportion,  and  break  before  the  year  is  over. 
So  that  in  the  ordinary  chairs  distributed  about  the  various  parts  of  a  public  or 
semipublic  institution  we  must  have  strength,  and  we  must  have  rubber  tips 
on  the  four  feet  and  a  rubber  tip  on  the  back  of  the  top  rail,  so  that  the  chairs,  if 
leaned  against  the  wall,  will  not  scratch  the  paint.  There  should  be  one  exception 
in  the  matter  of  tips  for  the  feet,  and  that  is  in  the  dining-rooms;  the  noise  incident 
to  the  rising  of  a  dining-room  full  of  nurses  is  almost  unbearable,  but  rubber  tips 


FURNITURE    IN   THE   HOSPITAL  191 

will  not  allow  the  chairs  to  slide  backward  and  forward  and  the  effect  is  most  awk- 
ward. A  felt  tip  instead  of  rubber  is  far  preferable  in  the  dining-room,  and  if  the 
floor  is  hard  wood,  oiled  or  waxed,  metal  tips  may  be  used;  they  make  some  noise, 
not  nearly  so  much,  however,  as  the  unshod  feet  of  the  chairs. 

Rockers. —  Roeking-ehairsmust  beconsidered  a  luxury  in  any  institution.but  they 
are  extremely  comfortable,  and  in  many  places  necessary.  A  convalescent  patient 
will  easily  tire  if  compelled  to  sit  bolt  upright  or  at  any  particular  incline,  and  he 
will  want  to  change  his  position  from  time  to  time.  He  can  do  this,  of  course,  by  a 
give-and-take  mechanism,  such  as  we  have  in  the  Morris  chair,  but  it  is  very  much 
easier  to  lean  forward  just  a  little  on  the  rocker  or  backward.  There  is  a  mistaken 
idea  that  the  back  of  a  rocking-chair  for  a  convalescent  patient  should  lean  far  back. 
This  is  not  according  to  the  best  comfort  of  the  patient.  A  very  few  degrees  back- 
ward from  the  severely  vertical  position  is  very  much  better,  and,  if  the  patient 
wants  to  lean  far  backward,  he  can  rest  his  feet  on  a  stool  or  hassock  or  another 
chair,  and  obtain  almost  a  reclining  position  if  desired.  The  rocking-chair  should 
have  broad  arms,  low  enough  so  that  the  elbows  of  the  patient  can  rest  easily  with- 
out pushing  the  shoulders  upward.  If  the  arms  are  broad  enough  to  hold  a  writing 
pad,  the  patient  will  be  able  to  adjust  his  arms  so  that  they  will  rest  easily  and  not 
be  strained. 

Metal  is  not  the  best  material  out  of  which  to  make  rockers.  In  the  first  place 
it  is  cold  to  the  touch,  and  if  the  joints  give  even  ever  so  little  the  play  allowed  will 
soon  develop  into  a  loose  joint,  and  the  next  step  will  be  a  break.  In  other  words, 
the  metal  chair  is  too  rigid,  and  will  break  before  it  will  give  ever  so  slightly.  The 
best  material  is  good,  strong,  well-seasoned  oak,  or  preferably,  if  it  can  be  had, 
hickory.  The  rocker  need  not  be  very  long  and  sweeping.  Very  few  patients  will 
want  to  or  should  rock  hard,  but  a  very  little  vibratory  movement  in  the  act  of 
rocking  to  and  fro  will  oftentimes  be  of  great  comfort  to  a  nervous  patient  and  serve 
to  quiet  him.  This  is  perhaps  more  true  of  women  than  men,  and  very  much  truer 
of  Southern  people  than  of  Northern  people,  because  in  the  South  nearly  everyone 
uses  a  rocker. 

The  rocker  for  nursing  mothers  and  wet  nurses,  and  to  be  used  by  the  nurses 
in  the  maternity  hospital,  should  be  very  low  and  narrow  and  without  arms.  It 
can  be  cane-seated  or  cushioned,  preferably  the  former,  for  sanitary  reasons,  and 
painted  or  enameled  to  conform  to  the  other  furniture  in  the  nursery. 

Morris  Chairs. — The  only  objection  to  the  Morris-chair  principle  is  the  uphol- 
stery, and,  as  usually  made,  it  is  not  very  sanitary  for  that  reason,  and  can  hardly 
be  made  so.  If  the  cover  is  of  leather,  it  cannot  be  fumigated,  and  can  never  be 
sterilized,  and  sometimes  this  will  be  required.  The  best  way  is  to  have  the  seat 
in  one  simple  piece  and  the  back  in  another,  and  to  have  these  upholstered  pieces 
covered  with  some  plain,  strong  material,  such  as  denim.  In  any  case,  the  up- 
holstered seat  and  back  of  the  Morris  chair  ought  to  be  enveloped  in  a  washable 
linen  fabric. 

There  is  a  new  Morris  chair  with  a  mechanism  that  permits  the  back  to  be 
brought  forward  or  lowered  into  complete  reclining  position  by  means  of  a  thumb 
push  at  the  side  of  the  seat  of  the  chair,  just  under  the  arm.  This  mechanism 
is  easy  to  work,  is  very  simple,  and  hence  does  not  get  out  of  order,  and  the  lock 
mechanism  of  it  is  perfect  enough  to  prevent  slipping.     It  is  shown  in  Fig.  95. 

Ward  Chairs. — In  a  great  many  institutions  there  is  a  desire,  amounting  almost 
to  an  obsession,  to  have  everything  in  the  ward  pure  white,  and  this  has  led  manu- 
facturers to  attempt  to  make  an  easy  chair  of  white  enamel  for  the  ward  patients. 
Figure  9o  shows  one  of  these  ward,  so-called,  easy  chairs.     It  is  reproduced  lure  as  a 


192  EQUIPMENT    OF    THE    HOSPITAL 

warning  rather  than  for  any  recommendation.  Generally  this  chair  is  made  large 
so  that  it  can  be  lined  with  pillows,  and  is  so  high  when  a  pillow  is  in  the  seat  that 
the  average  patient  will  not  be  able  to  touch  the  floor  with  his  feet;  and,  with  this 
pillow  idea  still  in  his  head,  the  manufacturer  has  made  the  chair  so  deep  from  front 
to  back  that,  even  with  one  or  two  pillows  at  his  back,  the  patient  will  still  cut  his 
legs  behind  the  knees  on  the  front  edge  of  the  seat.  The  mechanism  to  raise  or 
lower  the  back  is  made  very  rigid,  and  consequently  hard  to  work,  and  the  patient 
will  not  be  able  to  work  it  alone. 

If  this  chair  was  very  much  smaller  and  lower,  and  much  more  nearly  on  the 
pattern  of  the  average  rocker,  it  might  tie  of  service  in  the  ward,  chiefly  because  it 
would  be  sanitary;  and  if  it  was  made  to  conform  to  the  bends  of  the  body  it  would 


Fig.  95. — Morris  chair  with  push-button  mechanism. 

give  a  good  deal  of  comfort,  but  there  is  no  enameled  chair  made  of  metal  that  meets 
these  requirements. 

For  military  camps,  field  hospitals,  and  tuberculosis  shack  colonies  a  most 
comfortable  invalid  chair  can  be  made  out  of  a  barrel  cut  half-way  down  on  one 
side,  and  a  piece  of  heavy  canvas  tacked  across ;  or  with  a  common  saw  buck,  with 
a  back  made  of  two  uprights  and  a  cross-piece  nailed  to  one  side;  two  arms  can  be 
made  by  nailing  common  boards  across  the  forks  and  canvas  tacked  from  the  top 
of  the  back  to  the  round  coupling;  a  foot  stool  completes  as  comfortable  a  loung- 
ing chair  as  money  will  buy. 

Wheel  Chairs. — In  one  institution  that  has  distributed  about  the  house  some- 
thing more  than  fifty  wheel  chairs  of  supposedly  the  best  and  strongest  make,  there 
is  an  average  of  six  chairs  daily  in  the  repair  shop,  and  it  has  become  the  custom 
in  this  institution  for  the  repair  man  to  make  his  morning  rounds  for  broken  chairs. 


FIRNITTRF.    IN    THE    IWSI'ITAL 


193 


All  these  chairs  are  comparatively  new,  and  all  of  them  are  of  the  most  expensive 
make  of  wheel  chair.  These  facts  are  cited  merely  to  show  that  the  wheel-chair 
industry  is  not  on  a  very  efficient  basis. 

Figure  97  shows  perhaps  the  best  all-round  wheel  chair  for  institution  pur- 
poses now  on  the  market.  It  is  made  by  the  Gendron  Co.,  of  Toledo,  Ohio.  There 
are  a  number  of  weak  spots  in  this  chair;  the  extension  thai  slips  under  the  seat  of 
the  chair  to  hold  the  leg-piece  in  position  usually  breaks  easily;  the  hand  rail  at- 
tached to  the  wheel  breaks  easily  or,  rather,  comes  loose  from  the  wheel;  the  foot- 


Fit;.  96. — Morris  chair  of  white  enamel. 


piece  on  the  leg  extension  is  weak.  These  weaknesses  do  not  develop  in  ordinary 
use;  in  fact,  with  ordinary  care,  any  of  the  wheel  chairs  will  last  indefinitely,  and 
for  the  private  use  of  the  individual  in  his  own  home  will  do  nicely  and  last  a  long 
time,  but  in  institution  work  they  do  nol  gel  ordinary  care.  Oftentimes  the  nurse  is 
not  strong  enough  to  effectively  help  the  patient  into  the  chair  or  out,  and  hence  she 
raises  the  back  wheel  of  the  chair  so  that  the  foot- piece  touches  the  ground,  and 
then  she  has  the  patient  stand  upon  this  foot-piece  and  she  bears  down  on  the  back 
part  of  the  chair,  throwing  both  her  weight  and  that  of  the  patient  on  the  mechan- 
ism.    If  this  method  of  handling  the  patient    is   common  to  the  nurse,  it  is  very 


194 


EQUIPMENT    OF   THE  _  HOSPITAL 


much  commoner  in  the  case  of  the  orderly,  who  is  notoriously  careless  anyway, 
and  even  still  more  common  in  the  case  of  the  patient's  friends,  who,  not  satis- 
fied with  balancing  the  patient  against  the  leg  mechanism,  oftentimes  sit  upon  that 
mechanism  themselves  while  both  the  patient's  legs  are  perhaps  resting  on  one 
side,  or  they  sit  on  the  arm  of  the  chair  and  catch  their  heels  in  the  hand  rail. 
However,  there  seems  to  be  no  cure  for  these  inherent  weaknesses  in  even  the 
best  wheel  chair  made,  and  we  shall  have  to  get  along  with  what  we  have  until 
some  enterprising  manufacturer  can  accomplish  the  apparently  impossible  feat  of 
making  an  indestructible  wheel  chair,  or  perhaps  there  might  be  a  hint  to  some 
erstwhile  bicycle  maker,  whose  legitimate  business  has  gone  automobileward,  and 
he  may  make  for  us  a  tubing  or  metal  wheel  chair  at  a  price  that  institutions  can 
afford  to  pay. 


Fig.  97.— Wheel  chair. 

If  there  are  steps  to  be  negotiated  by  the  wheel  chairs  in  the  institution  in  getting 
in  and  out  of  doors,  the  chair  with  the  single  small  rear  wheel  will  not  serve  the 
purpose,  because  the  chair  cannot  be  balanced  on  the  single  wheel  after  the  fashion 
employed  with  baby  carriages,  and  two  rear  wheels  will  be  necessary. 

Commode  Chair. — A  very  essential  piece  of  furniture,  and  one  that  must  be  kept 
at  convenient  intervals  all  over  any  institution  where  there  are  sick  people,  is 
shown  in  Fig.  98.  This  is  at  best  not  a  very  ornamental  piece  of  furniture,  but  the 
one  in  the  cut  is  perhaps  the  least  suggestive  of  its  vulgar  use.  The  legs  of  this 
chair  should  be  shorter  than  those  usually  furnished  by  the  manufacturers.  There 
is  a  receptacle  under  the  seat  for  the  chamber  vessel,  and  if  the  vessel  does  not  fit 
tight  up  against  the  hole,  it  should  be  made  to  do  so  with  a  block  of  wood,  other- 
wise urine  will  find  its  way  out  of  the  vessel,  and  sometimes  onto  the  floor.     If 


11  1,'MI'l  RE    I\    THE    HOSPIT  ih 


195 


the  seat  of  the  chair  is  low  enough  there  can  he  a  properly  shaped  cushion  of  some 
sort  for  seal  and  back,  to  be  used  when  the  chair  is  acting  merely  as  an  ordinary 
piece  of  furniture  and  its  necessary  but  homely  office  need  not  he  suspected. 

Figure  99  shows  another  and  improved  form  of  commode  adaptable  as  a  piece 
of  private-room  furniture;  it  maybe  used  as  a  jardiniere  or  stool.  It  is  of  white 
porcelain,  double-hinged,  so  that  the  one  pair  of  hinges  operate  the  outer  lid  as  well 
as  the  inner.  It  has  knob  feet  for  sliding  over  either  bare  floors  or  carpet.  This  is 
made  by  the  Scanlan  Morris  Co.,  of  Madison,  Wisconsin. 

These  same  people  also  make  another  very  useful  article,  shown  in  Fig.  101, 
and  which  they  call  the  white  line  cabaret  commode.  There  are  hangers  inside 
for  bed-pan,  slop-bowl,  male  and  female  urinals.  It  opens  on  three  sides  and  is 
consequently  easily  cleaned. 


Fig.  9S. — Commode  chair. 

Chairs  for  Insane  Persons. — It  often  becomes  necessary,  especially  in  hospitals 
for  the  care  of  the  insane,  to  get  patients  out  of  bed  against  their  inclinations. 
They  have  perhaps  been  shackled,  and  compelled  to  remain  for  a  long  period  of 
time  in  a  more  or  less  cramped  position.  For  the  best  good  of  these  unfortunate 
people  they  ought  to  be  sat  up  frequently,  but,  unless  they  can  afford  the  luxury  of 
a  constant  attendant,  it  will  be  necessary  to  find  some  sort  of  chair  in  which  they  can 
be  controlled  as  to  arms  and  legs  and  body.  There  is  a  chair  made  for  the  pur- 
pose that  has  very  broad  and  heavy  feet,  so  that  the  patient  who  happens  to  be 
shackled  cannot  toss  about  and  throw  the  chair  over  and  injure  himself.  This 
chair  is  provided  with  rings  in  the  back  part  of  both  sides,  and  there  is  a  strap  that 
can  be  snapped  into  the  rings,  and  it  will  hold  firmly  across  the  upper  parts  of  the 
patient's  thighs  in  the  bend  of  the  body.     There  are  other  rings  part  way  up  the 


196 


EQUIPMENT    O"    THE    HOSPITAL 


Fig.  99. — White  Line  sanitary  commode.  Fig.  100. — White  Line  sanitary  commode. 


Fig.  101. — White  Line  cabaret. 


FURNITURE    IN   THE    HOSPITAL  197 

back  of  the  chair,  out  of  the  patient's  reach,  and  a  strap  with  snap  buckle  fastens 
across  the  chest  of  the  patient,  about  the  height  of  the  diaphragm.  There  are  leg 
and  foot  extensions  cither  in  one  piece  or  two,  and  there  are  strap  arrangements  at 
the  back  of  each  extension  about  the  height  of  the  knee,  so  that  straps  can  be  fast- 
ened about  the  lower  leg.  If  possible  it  is  always  advisable  to  leave  the  patient's 
hands  and  arms  free,  at  least  below  the  elbows.  Sometimes  this  cannot  be,  as  they 
get  the  straps  off  the  rest  of  the  body,  hence  there  are  rings  in  the  under  part  of  the 
arms  of  the  chair,  and  there  are  elbow  pieces  made  of  padded  leather  into  which 
the  elbow  fits  snugly,  with  a  padded  strap  in  the  bend  of  the  elbow,  and  these  elbow 
shackles  are  snapped  to  the  rings  through  holes  in  the  chair-arm.  If  the  patienl 
cannot  be  allowed  even  wrist  movement  for  comfort,  the  horizontal  piece  of  the 
elbow  shackel  extends  to  the  end  and  fastens  about  the  wrist  with  a  strap. 

A  chair  like  this  can  be  easily  made  out  of  metal  to  meet  the  particular  require- 
ments of  any  case  that  promises  to  extend  over  a  long  period  of  time,  or  it  can  be 
bought  of  most  of  the  hospital-supply  manufacturers. 

RUGS 

Well  people  in  the  hospital — nurses,  interns,  and  administrative  officers — have 
the  right  to  be  as  comfortable  as  possible,  therefore  they  will  most  always  have 
pictures  on  their  walls,  draperies  in  the  windows,  and  rugs  on  the  floors;  these 
rugs  can  sometimes  be  made  large  enough  to  practically  fit  the  room,  and  they  can 
be  cleaned  with  a  vacuum  cleaner,  or  rolled  up  and  cleaned  out  of  doors  when 
necessary.  Rugs  in  private  rooms  are  concessions  to  luxury  and  are  unsanitary 
at  best;  they  should  be  vacuum-cleaned  every  day,  and  sterilized  throughly  when- 
ever a  patient  leaves  the  apartment  as  a  part  of  the  general  cleaning;  therefore, 
they  cannot  be  very  large,  say  3  by  6  feet;  such  rugs  can  be  taken  up  when  the  bed 
has  to  be  moved,  and  they  are  small  enough  so  that  one  or  two  bed-posts  will  not 
have  to  stand  on  them,  which  is  objectionable. 

Private  Ward  Rugs. — The  private  wards  of  a  hospital  can  be  made  much  more 
comfortable  looking  and  cozy  if  they  have  one  large  or  several  small  rugs  on  the 
floor,  and,  since  it  is  highly  necessary  to  maintain  the  utmost  cleanliness  and  sani- 
tation in  these  wards,  a  hard,  bright-colored  porous  rug  will  answer  the  purpose 
better  than  a  Wilton  or  Brussels,  and  there  is  such  a  rug  made  of  Southern  grasses, 
very  economic  in  price,  very  easily  cleaned  or  scrubbed,  and  capable  of  fumigation 
or  steaming.  It  is  sometimes  known  as  the  Crex,  but  about  the  same  thing  is 
sold  under  different  names  in  most  furniture  and  carpet  houses.  These  rugs  cost 
about  87  for  a  0  by  12  feet,  or  $1  for  a  3  by  6  feet.  They  do  not  wear  very  well 
on  a  much-used  floor  or  in  the  larger  sizes. 

It  will  not  be  possible  to  include  rugs  among  the  furnishings  of  a  public  ward; 
first,  because  these  wards  are  very  much  larger,  and  next,  because  ii  is  impossible 
to  control  the  class  of  patients  occupying  them  and  the  friends  who  visit  them. 

SCREENS 

Bed  Screens  in  Wards. — The  screen  to  shield  patients  during  the  bed-bathing 
or  dressing  or  examination  is  a  rather  important  item.  There  are  many  such 
screens  sold  on  the  market,  and  none  of  them  is  acceptable;  usually  they  are  frail. 
It  they  are  of  metal  they  are  too  heavy  to  be  moved  readily,  especially  when  the 
materia]  is  of  heavy  cloth  or  canvas,  and  where  they  have  castors  the  castors  are 
usually  out  of  order.     If  they  are  made  of  wood  and  are  light,  the  slightest  push 


198 


EQUIPMENT    OF   THE    HOSPITAL 


knocks  them  over,  and  the  paint  soon  is  worked  off  by  cleaning,  and  they  are  not 
very  sanitary. 

Generally  speaking,  these  screens  have  hinges  that  are  difficult  to  clean,  and  they 
are  either  left  uncleaned  or  require  very  much  time  of  the  nurses  to  keep  them  in 
order.  Figure  102  shows  one  kind  of  screen  that  answers  a  certain  demand;  it 
cannot  be  used  for  private  rooms,  as  it  is  too  large  and  heavy. 

Some  institutions  are  equipped  with  screens  about  each  bed;  a  cable  is  stretched 
on  standards  about  5  feet  high,  one  at  each  post;  there  is  a  width  of  light  canvas 
or  heavy  sheeting  for  each  side  and  each  end;  the  screens  can  be  pulled  back  when 
not  in  use  and  fastened  to  the  standards.  This  kind  of  screen  adds  greatly  to  the 
laundry  if  they  are  kept  clean,  and  if  not  kept  clean  they  are  a  menace  to  patients 


Fig.  102. — Bed  screen  for  use  in  wards. 

on  the  score  of  sepsis.  At  any  rate,  they  should  not  be  used  except  when  abso- 
lutely necessary,  because  they  interfere  very  much  with  the  circulation  of  air. 

There  is  another  screen,  made  of  two  metal  standards,  3,  4,  or  6  feet  apart,  each 
one  supported  on  widespread  legs.  The  cloth  is  stretched  across;  one  side  of  the 
bed  can  be  shut  off  by  such  a  screen,  and  its  greatest  disadvantage  is  that  the  legs 
are  always  in  the  way  and  it  is  constantly  getting  kicked  over. 

Private  Room  Screens. — The  three  part,  straight-sided,  ordinary  house  screen, 
made  of  wood  to  match  the  furniture,  with  screen  material  of  some  pretty-figured 
wash  stuff,  probably  answers  all  the  requirements  of  private  rooms. 

Door  Screens. — Every  door  to  a  private  room  or  private  ward  of  a  hospital — 
indeed,  every  door  of  every  room  intended  for  the  privacy  of  individuals — should 
have  some  sort  of  protective  device  that  can  be  made  to  take  the  place  of  a  door, 
that  will  at  once  give  the  occupant  of  the  room  the  air  and  light  from  the  outside 


FURNITURE    IN   THE    HOSPITAL 


199 


and  protect  him  from  the  gaze  of  passers  by.  Figure  103  shows  such  a  screen,  one 
which  may  be  well  accepted  as  suitable  for  any  place  where  such  a  device  is  needed. 
The  frame  is  made  of  wood  to  correspond  with  the  door.  Simple  detachable  brass 
rods  are  placed  across  the  upper  and  lower  margins  of  each  opening,  so  that  hem- 
stitched linen  or  dimity  or  cheese-cloth  fabrics,  with  a  double  hem,  can  be  stretched 
across  the  openings.  These  fabrics  may  be  changed  whenever  desired.  These 
screens  wherever  used  give  such  complete  privacy  to  occupants  of  rooms,  and  allow 
such  free  circulation  of  light  and  air,  that  it  seems  almost  impossible  to  do  without 


.  103.— Door  screen. 


them  after  they  have  been  once  used.  They  at  once  protect  the  privacy  of  the 
patient  and  admit  the  friendly  sounds  of  life  and  bustle  on  the  outside,  so  grateful 
to  convalescents. 


THE  PORTABLE  BATH 

There  is  no  unanimity  of  opinion  that  the  portable  bath  is  a  necessary  or  even 
useful  piece  of  institution  mechanism.  In  some  hospitals,  notably  the  Johns  Hop- 
kins, it  is  used  regularly  and  in  a  routine  way  in  the  wards.  In  some  of  the  insane 
hospitals  it  is  employed  for  the  long-continued,  or  even  the  continuous,  bath  for 
unruly,  violent,  or  nervous  patients;  some  dermatologists  employ  it  for  continuous 


200  EQUIPMENT    OF   THE    HOSPITAL 

bath  in  pemphigus,  and  a  few  surgeons  like  it  for  continuous  bath  for  bad  burns. 
There  are  objections  to  the  portable  bath. 

Generally,  quite  exact  temperatures  are  ordered  for  patients  where  a  portable 
bath  is  required,  and  generally,  also,  the  bath  is  expected  to  cover  long  periods  of 
time.  It  usually  happens  that  there  is  no  running  water  in  the  immediate  neigh- 
borhood that  can  be  conveniently  used,  and  it  almost  always  happens  that  the 
outlet  of  the  bath-tub  cannot  be  made  to  reach  a  check  or  sewer  opening;  therefore, 
the  temperature  must  be  raised  or  lowered  by  means  of  the  bucket  or  vessel,  and, 
unless  extreme  care  is  taken,  the  patient  is  often  badly  burned  with  hot  water  or 
chilled  with  cold. 

In  order  to  reach  its  highest  perfection  in  any  of  the  cases  referred  to  there  should 
be  hot  and  cold  water  for  continuous  intake,  and  a  sewer  outlet,  leading  directly 
from  the  bath  outlet,  in  order  that  the  water  may  be  continuously  changed  and  a 
correct  temperature  kept.  Most  of  these  portable  wheel  baths  have  a  suspension 
bed  inside,  upon  which  the  patients  may  be  lowered  or  raised  at  will,  and  there 
are  a  few  cases  of  one  sort  or  another  where  they  serve  a  most  excellent  purpose, 
but  in  the  vast  majority  of  cases  where  a  portable  bath  would  serve  the  purpose 
a  permanent  tub  would  do  quite  as  well. 

It  is  not  certain  that  the  tubbing  of  typhoids  and  other  high-fever  cases  cannot 
ordinarily  best  be  done  in  the  stationary  baths  about  the  wards,  and  in  a  number 
of  excellent  institutions  that  have  the  wheel  baths,  the  Burr  baths,  Kelly  pads, 
and  rubber  sheets  for  the  bathing  of  patients  in  their  own  beds  the  stationary  bath 
in  the  regular  bath-room  is  usually  employed;  this  for  a  number  of  reasons.  First, 
the  tubbing  of  patients  is  usually  a  sloppy,  noisy,  fussy  procedure,  and,  having  to 
be  repeated  at  frequent  intervals,  it  interferes  very  much  with  the  comfort  and  quiet 
of  other  patients  if  it  is  done  in  the  ward.  Then  it  slops  the  floors  very  much  and 
often  the  beds  are  wet,  and  the  whole  procedure  is  a  sort  of  makeshift  that  is  not 
the  case  where  a  patient  is  gently  lifted  to  a  stretcher  or  cart  and  taken  to  the 
permanent  bath-room.  Moreover,  the  continuous  bath  for  pemphigus  is  losing 
favor  with  most  dermatologists,  and  surgeons  generally  have  gone  back  to  the  dry 
powder  or  to  the  open-air  treatment  of  burns.  In  one  institution,  where  the  port- 
able bath  is  strongly  advocated  and  frequently  used,  there  is  the  apparently  in- 
congruous condition  of  a  separate  room  fitted  up  for  it,  with  taps  for  hot  and  cold 
water  to  run  in  at  the  head,  and  with  an  outlet  situated  conveniently  at  the  foot,  so 
that  new  water  can  be  continuously  run  in  at  one  end  while  the  used  water  runs  out 
at  the  other.  It  would  be  interesting  to  learn  just  wherein  the  portable  feature  is 
advantageous  under  such  circumstances,  since  the  patient  must  be  brought  to  this 
room  quite  the  same  as  though  the  tub  were  an  ordinary  one  fixed  in  the  floor;  the 
raising  and  lowering  device  has  no  special  advantage,  as  the  water  can  be  accom- 
modated to  the  patient  quite  as  easily  as  the  patient  can  be  raised  or  lowered  to  fit 
the  height  of  the  water. 

DECORATION  IN  INSTITUTIONS 

The  furnishing  of  private  rooms  of  a  hospital,  or  similar  institution  requiring 
a  particularly  high  order  of  sanitation,  is  not  a  very  simple  matter,  and  the  simpler 
the  furnishing  the  more  difficult  does  the  problem  become,  because  of  the  necessity 
to  preserve  appearances.  This  is  not  quite  so  true  regarding  the  furnishing  of 
private  wards,  because  the  straining  for  effect  and  the  necessity  for  "coziness" 
are  not  so  great.  For  instance,  the  question  of  rugs  and  draperies,  curtains,  couches, 
and  other  furniture  is  a  matter  of  a  good  deal  of  importance.     A  bare  room  looks 


FURNITURE    IN    THE    HOSPITAL  201 

uninviting,  while  draperies  and  table  covers  take  away  from  the  room  much  of  that 
coldness  and  unhospitality  felt  by  most  sick  people.  Yet  these  articles  of  furni- 
ture are  dirt  catchers  and  vermin  containers,  and  if  the  rugs  and  draperies  are  not 
cleaned  frequently,  the  appearance  of  the  room  is  worse  than  one  furnished  in  ihe 
greatest  simplicity,  besides  being  positively  dangerous.  It  costs  a  good  deal  to 
launder  linen  curtains  and  dresser  covers  and  couch  covers,  yet  this  must  be  done 
very  frequently  if  the  room  is  to  make  a  presentable  appearance. 

Medical  literature  is  interspersed  freely  with  arguments  for  and  against  pictures 
on  the  walls  of  the  sick  room,  the  presence  of  books,  and  the  circulation  of  magazines, 
and  there  is  now  almost  a  concensus  of  opinion  that  books  may  not  be  circulated 
or  kept  in  sick  rooms — that  they  cannot  be  fumigated  efficiently — and  most  mem- 
bers of  the  profession  object  strenuously  to  pictures  on  the  walls.  It  may  be 
questioned  whether  a  good  deal  of  this  protest  against  adequate  furniture  in  a  sick 
room  is  not  straining  at  the  small  things;  it  is  quite  certain  that  the  mental  rest- 
fulness  of  a  well-furnished  room  will  oftentimes  add  greatly  to  the  comfort  and 
well  being  of  the  patient,  and  more  than  compensate  for  any  harm  that  can  come, 
especially  if  due  diligence  is  employed  to  keep  things  clean  and  sanitary,  but  per- 
haps there  is  a  happy  medium  that  will  permit  of  proper  rugs  on  floors  and  lace 
draperies  in  the  windows,  with  perhaps  decorations  of  cheneille  or  similar  stuff 
with  linen  covers  in  figures  on  the  dressers  or  tables.  This  arrangement  must  always 
be  presaged,  however,  by  the  understanding  that  these  rooms  are  to  be  well  kept, 
that  the  linens  are  to  be  changed  at  least  often  enough  to  prevent  their  use  by  more 
than  one  patient,  and  there  is  nothing  more  cold  or  disagreeable  and  discomforting 
than  a  bare  floor,  and  in  these  days,  wdien  vacuum  cleaners  can  be  had  that  do  good 
work  with  rugs,  and  when  every  room  is  supposed  to  be  well  fumigated  with  an 
effective  germ  destroyer,  there  would  seem  to  be  no  adequate  reason  why  a  patient's 
comfort  and  luxury  may  not  be  considered. 

As  for  pictures  on  the  walls  that  is  a  matter  for  each  individual  institution, 
and,  if  any  are  used,  they  should  depict  cheerful  subjects,  likely  to  take  the  mind 
of  the  occupant  away  from  pain  and  the  depressing  influences  of  illness — prints  of 
good  originals,  scenery,  interesting  ruins,  and  historical  events.  It  should  be  a 
part  of  the  cure  in  many  cases  to  have  a  patient's  mind  diverted,  and  there  is  not 
very  much  in  bare  walls  to  hold  one's  attention  away  from  himself.  In  children's 
hospitals  heavy  stensils  may  lie  used  in  colors,  either  as  a  dado  or  frieze.  There 
are  whole  stories  of  these  now — "  Mother  Goose,"  "  iEsop's  Fables,"  etc. 

Of  course,  if  the  institution  is  to  allow  dust  to  accumulate  behind  these  pictures, 
and  allow  the  pictures  themselves  to  be  defaced  and  soiled,  that  is  a  proposition 
rather  of  censure  for  the  institution  than  of  the  practice  of  having  pictures.  An 
institution  that  does  not  thoroughly  clean  every  part  of  every  room  as  soon  as 
vacated  by  a  patient  and  before  another  is  admitted  is  neglecting  one  of  the  very 
first  principles  of  institution  management,  and  when  we  talk  of  hospital  practice, 
or  institution  administration,  we  are  assuming  that  things  are  done  properly. 
Therefore,  it  should  not  be  out  of  place  to  furnish  cozy  surroundings  and  some  of 
the  elements  of  luxury  to  patients  in  private  rooms  of  an  institution,  whether  it  be 
a  sanitarium,  insane  asylum,  or  general  hospital. 

Similar  conditions  do  not  exist  in  wards,  either  small  or  large.  Even  where  there 
are  two  patients  in  a  room  it.  will  be  found  impossible  for  many. months  at  a  time 
to  adequately  fumigate  and  clean  the  room,  because  there  will  always  be  at  least 
one  patient  present.  In  wards  accommodating  several  patients,  such  fumigation 
and  proper  cleaning  can  only  be  done  under  the  greatest  emergency,  such  as  the 
appearance  of  a  contagious  disease,  when  all  the  patients  must  be  taken  out  and 


202  EQUIPMENT    OF   THE    HOSPITAL 

the  room  fumigated  and  cleaned  thoroughly,  and  this  will  be  found  oftentimes  to 
require  a  week  or  more,  because  the  floors  must  be  scrubbed  and  filled  and  refinished, 
the  walls  must  be  painted,  and  all  of  the  wiring  gone  over,  the  pipes  and  radiators 
thoroughly  cleaned,  so  that  in  these  wards  it  would  be  impossible  to  have  draperies 
in  the  windows  or  covers  of  heavy  goods  on  the  tables  and  dressers. 

It  is  not  quite  so  certain  that,  even  in  large  wards,  a  few  carefully  framed,  cheer- 
ful pictures  would  not  be  appropriate,  and  if  there  is  a  proper  fumigation  room  in  the 
institution  these  can  be  removed  to  it  occasionally  and  every  visage  of  infection 
destroyed. 

BOOKS 

As  for  books  for  patients,  there  is  no  doubt  they  may  carry  within  their  pages 
micro-organisms  that  cannot  be  destroyed  by  any  ordinary  fumigation.  Numer- 
ous tests  have  been  made  under  laboratory  conditions  by  the  great  libraries  to 
determine  the  facts  on  this  subject,  and  it  has  been  found  that  even  so  easily 
destroyed  a  germ  as  the  pyocyaneus,  planted  within  the  leaves  of  a  volume,  will 
resist  the  most  extensive  formaldehyd  fumigation.  So  that  while  books  and  maga- 
zines would  be  in  many  cases  most  excellent  diversion  for  patients,  the  dangers 
arising  from  their  promiscuous  distribution  are  so  great  that  the  practice  should 
not  be  entertained.  Books  may  be  brought  in  by  the  friends  of  patients,  and,  if 
there  is  an  adequate  control  of  their  circulation,  there  would  seem  to  be  no  good 
reason  why  they  might  not  be  passed  from  one  to  another  clean  case,  or  from  one 
case  to  another  in  which  there  is  no  micro-organic  influence  at  work;  but  the 
circulating-library  business  of  an  institution  is  a  dangerous  one,  and  ought  not  to 
be  encouraged. 

RECEPTACLES  FOR  CLOTHING 

Private  rooms  usually  have  ample. closet  room  for  patients'  clothing,  and  are 
furnished  with  chiffoniers  and  dressers  sufficient  for  all  the  needs  of  the  occupant 
of  the  room.  There  are  other  parts  of  the  hospital,  however,  in  which  there  must 
be  accommodation  for  the  keeping  of  clothing,  hats,  shoes,  and  the  hanging  of 
garments.  Figures  104  and  105  show  a  most  convenient  form  of  locker.  Usually 
it  is  made  two  sections  in  one  piece,  each  section  15  inches  square  on  the  inside 
and  about  5  feet  high,  with  beveled  top.  It  may  be  had  with  one,  two,  three,  or 
four  compartments  or  stories,  according  to  the  use  to  which  it  is  to  be  put.  The 
single  compartment  locker  has  a  far  greater  usefulness  in  many  parts  of  the  house 
than  that  in  which  there  are  divided  compartments,  because  it  permits  the  hanging 
of  dresses,  trousers,  and  coats  without  folding. 

There  is  a  shelf  a  few  inches  from  the  floor  on  which  the  shoes  may  be  kept,  and 
a  second  shelf  a  few  inches  below  the  top  for  hats  and  small  articles,  while  the  rest 
of  the  locker  is  fitted  with  hangers.  This  locker  is  a  most  useful  piece  of  furniture 
for  private  wards,  for  the  surgeons'  dressing-rooms,  and  in  the  operating  suites 
for  the  nurses'  locker  room  and  for  the  use  of  visiting  physicians.  It  is  fitted  with 
a  good  lock,  with  upper  and  lower  lock  bar  that  prevents  the  prying  open  of  the 
door  either  from  above  or  below.  It  takes  up  very  little  room,  and,  being  made  in 
two  sections,  is  flexible  enough  to  be  used  in  private  wards.  A  sufficient  number 
of  these  lockers  can  be  placed  against  the  wall  at  almost  any  part  of  the  room  not 
occupied  by  the  bed,  and  its  use  is  a  source  of  great  satisfaction,  not  only  to  the 
occupants  of  the  wards,  but  to  the  nurses  and  orderlies  and  workers  generally, 


FURNITURE    IX   THK    HOSPITAL 


ju:; 


because  it  is  not  an  infrequent  occurrence  that  patients  will  take  each  other's  things 
unless  they  arc  kept  under  lock  and  key. 


Fig.  104. — Locker  for  elothin 


Fig.  105. — Locker  for  clothing. 


This  is  rather  an  inexpensive  article  of  furniture,  costing  about  $5  for  each 
section.  If  it  is  not  necessary  to  hang  up  outer  garments  and  night  clothes,  the 
lockers  may  be  in  two  sections,  or  even  three  or  four,  and  then  can  be  used  like  a 
chiffonier. 


EQUIPMENT  OF  THE  OPERATING-ROOM 


There  is  a  disposition  among  surgeons,  interns,  and  nurses  to  litter  up  opera- 
ting-rooms with  apparatus.  Perhaps  such  a  statement  as  this  ought  to  be  qualified 
by  stating  that  where  this  tendency  does  exist  a  good  many  surgeons  operate. 
In  other  words,  in  the  modern  hospital  that  practices  the  open-door  policy,  allowing 
almost  any  surgeon  to  schedule  an  operation,  each  surgeon  will  want  a  lot  of  things 
of  his  own,  special  instruments  and  special  technic.     In  order  to  accommodate  each 


r     ' 

Fig.  106. — Operating-room  too  full  of  furniture. 

one  of  these  men  in  their  own  way,  the  operating-room  interns  and  nurses  keep 
adding  things  to  the  operating-room  equipment  until  they  have  right  at  their 
elbow  almost  everything  that  anyone  can  want  for  any  operation  under  any  cir- 
cumstances. In  order  to  accommodate  all  these  etceteras  of  operating  procedure 
it  is  necessary  to  have  a  lot  of  shelf  stands  and  tables,  until  the  operating-rooms 
become  so  clogged  with  paraphernalia  that  no  one  can  move  about. 

The  ideal  operating-room  can  be  obtained,  of  course,  when  there  is  only  one 
man  who  works  there.  The  furnishing  of  such  a  room  can  be  of  the  plainest  sort, 
and  ought  to  be;  the  operating  table,  the  instrument  tray  that  sets  above  the 

204 


KtiUIl'MKNT    OK    THE    OI'KRATING-ROOM 


_'n:, 


patient,  a  tabic  and  stool  for  the  anesthetist,  and  perhaps  a  shelf  stand  over  in  the 
far  corner  of  the  room  are  about  the  only  pieces  of  furniture  needed.  Everything 
else  can  be  in  an  adjoining  room,  pre- 
sided over  by  one  careful  nurse,  who 
can  pass  out  additional  instruments, 
packages  of  combination,  sponges  or 
packing,  and  who  can  take  away  the 
used  sponges.  It  goes  without  saying 
that  this  annex  room  must  be  a  sacred 
place,  not  open  to  the  intrusion  of 
anyone,  and  the  presiding  nurse  must 
be  one  who  can  be  implicitly  relied  on, 
both  as  to  efficiency  and  conscientious- 
ness. Such  an  arrangement  as  this 
presupposes  a  single  surgeon,  with  a 
minimum  number  of  assistants  and  a 
simple  technic. 

The   two   extremes   of    operating-     . 
room  furniture  are  shown  in  Figs.  106 
and  107. 

In  Dr.  William  J.  Mayo's  room  a 
"sister"  is  the  only  assistant,  and  she 
works  opposite  the  operator  all  the 
time,  year  in  and  year  out.  There  is 
a  nurse  placed  over  against  a  far  wall 
where  the  instruments  are,  and  whose 
duty  it  is  to  see  that  the  operator  gets 
what  he  calls  for  and  to  keep  out  of 
the  way.  An  intern  is  present  in  the 
room,  having  brought  the  patient  up- 
stairs; he  will  also  return  the  patient  to 
bed;  his  only  other  duties  are  to  read  ; 
an  extract  from  the  record  when  called 
upon  and  to  thread  a  needle  occasion- 
ally. He  renders  no  other  assistance. 
This  system,  however  unsatisfactory 
it  may  be  from  the  standpoint  of 
the  intern  and  nurse  in  the  matter 
of  training,  is  certainly  simple.  The 
operator  has  a  perfectly  trained  assist- 
ant, and  does  his  work  expeditiously 
and  without  any  unnecessary  fuss  at 
the  hands  of  beginners. 

In  the  Michael  Reese  Hospital 
(Fig.  106)  there  are  always  five  assist- 
ants and  generally  six  an  anesthetist, 
a  senior  assistant,  and  three  nurses,  an 
instrument  nurse,  sponge  nurse,  ami 
"supe"  to  take  away,  count,  and  hang 
up  used  sponges,  pass  needed  articles  to  the  instrument  nurse,  etc.  Generally  there 
is  a  second  senior  medical  assistant  to  hold  retractors,  especially  in  deep  abdominal 


206 


EQUIPMENT    OF   THE    HOSPITAL 


work.  Different  institutions  have  different  ways  of  doing  these  things,  all  the 
way  from  the  simplicity  of  Dr.  Wm.  J.  Mayo  to  the  intricate  technic  of  the  Michael 
Reese  Hospital.  It  is  the  personal  judgment  of  the  author  that  there  is  a  happy 
medium  between  these  two  extremes,  and  that  a  small  amount  of  operating-room 
furniture  can  be  used  advantageously;  but  it  should  be  kept  out  against  the 
walls  and  away  from  the  center  of  the  room.  Of  course  there  is  a  fair  proba- 
bility that  Dr.  Wm.  J.  Mayo  goes  farther  in  the  way  of  simplicity  in  furniture,  in 
order  to  accommodate  his  custom  of  wheeling  the  operating  table  about  the  room  at 

various  interesting  stages  of  the  proce- 
dure, to  show  the  field  to  the  clinic  oc- 
cupying two  sides  of  the  room. 

Operating  Tables. — It  is  a  peculiarity 
of  the  surgical  profession  that,  as  soon  as 
one  of  its  members  has  got  far  enough 
along  to  be  on  speaking  terms  with  a  def- 
inite technic,  the  first  thing  he  does  is 
to  develop  original  ideas  on  the  subject 
of  operating  tables,  until  there  are  about 
as  many  designs  as  there  are  surgeons. 
Fortunately,  most  of  the  new  ideas  are  de- 
veloped around  tables  already  in  the  rooms, 
and  consist  of  pieces  that  fit  into  sockets 
made  for  something  else — shoulder  pieces 
leg  pieces,  head  pieces,  and  pieces  to  ac- 
commodate almost  every  inch  of  the  body 
for  some  special  operation;  and  fortu- 
nately, again,  storage  rooms  for  junk  are 
usually  at  hand  to  swallow  up  in  their 
dusty  caverns  most  of  these  ingenious  de- 
vices "until  they  are  needed." 

The  only  clearly  discernible  fact  about 
operating  tables  is  that  no  two  operators 
can  be  appeased  by  any  one  table,  and 
the  wise  hospital  administrator  who  needs 
a  table  will  fix  the  maximum  price  he  is 
willing  to  pay  for  it,  and  give  the  operator 
who  is  to  use  it  carte-blanche  within  those 
figures  to  go  and  buy  what  he  wants.  If 
several  surgeons  are  to  use  it,  he  has  one 
of  two  horns  of  the  dilemma  to  choose 
from — either  give  over  the  selection  to  the  surgeon  who  seems  to  know  what  he 
wants,  and  makes  the  greatest  row  if  he  doesn't  get  it,  or  ignore  all  of  them  and 
buy  the  table  himself.  He  can  then  stay  out  of  the  operating-rooms  until  some 
new  and  greater  calamity  comes  to  divert  everybody's  attention. 

If  this  latter  course  is  chosen,  a  few  principles  in  operating  tables  ought  to  be 
kept  in  mind.  In  the  first  place  simplicity  is  a  jewel,  and  complications  breed 
woe  at  critical  times.  The  table  that  "works  like  a  charm"  in  the  show  rooms 
generally  fails  to  work  at  all  when  some  instantaneous  move  must  be  made,  per- 
haps to  save  a  patient  who  has  suddenly  gone  to  the  bad.  Any  one  of  half  a  dozen 
tables  readily  admit  of  a  satisfactory  Trendelenburg,  Cunningham,  and  the  vari- 
ous lithotomy  positions. 


s*c 

hi 

Fig.  108. — McArthur's  head  rest. 


EQUIPMENT   OF  THE   OPERATING-ROOM 


207 


There  are  some  points  about  the  Hartley  table,  made  by  the  Hospital  Supply 
Co.,  after  the  design  of  Dr.  William  Hartley,  of  New  York,  that  make  it  perhaps 
the  most  satisfactory  of  all,  taking  everything  into  consideration,  that  it  admits 
of  the  Trendelenburg,  lithotomy,  and  Cunningham  positions  in  all  their  variations. 
Only  in  one  or  two  slight  particulars  does  it  fall  short;  one  of  these  is  that  the 
shoulder  braces  for  the  position  of  perineal  prostatectomy  are  too  low  down,  as  they 
allow  the  patient  to  slip  forward,  so  that  the  surgeon  must  work  over  the  edge  of 
the  table,  which  prevents  free  access  to  the  field  of  operation.     This  can  be  remedied, 


Fig.  109. — Hartley  operating  table  in  Trendelenburg  position. 


however,  by  a  little  different  design  of  the  shoulder  brace,  giving  it  an  arm  that 
will  throw  the  brace  about  4  inches  lower  toward  the  foot  of  the  table.  This  arm 
can  be  made,  with  sliding  set-screw  attachment,  to  meet  the  requirements  in  any 
size  of  patient.  Another  detail  in  which  the  Hartley  table  seems  to  not  quite  meet 
all  the  demands  in  brain  surgery  is  in  the  fixed  head  rest.  These  head  rests  have  an 
extension  arm,  and  they  do  not  provide  against  vibration  in  chiseling  operations 
which  they  are  intended  to  do.  Dr.  L.  L.  McArthur,  Dean  of  the  Michael  Reese 
surgical  staff,  has  added  to  the  table  for  brain  operations  a  simple,  strong  head 
rest,  composed  of  a  heavy  upright  piece  of  tubing  set  upon  three  legs:  a  strung 


208 


EQUIPMENT    OF   THE    HOSPITAL 


cup  is  fixed  at  the  top  of  this  stand  to  rest  the  head  in.  This  form  of  head  rest 
can  be  raised  or  lowered,  either  by  set-screw  attachment  at  the  junction  of  the  legs 
or  by  archimedian  screw  or  worm  gear;  the  head  cups  are  made  in  several  forms, 
to  fit  the  head  in  any  position.  The  Hospital  Supply  Co.  makes  this  head  piece, 
a  cut  of  which  is  shown  in  Fig.  108. 

The  hot-water  containers  in  some  operating  tables  seem  not  to  be  desired  by 
most  surgeons,  and,  where  the  hot-water  containers  are  present,  they  are  rarely 
used,  except  in  cases  of  small,  very  delicate  children;  and  for  work  with  children, 
the  complexities  of  the  Hartley  table  are  in  no  demand  whatever,  so  that  for 


Fig.  110. — Hartley  table  in  position  for  kidney  work. 

childrens'  surgery  the  simplest  form  of  table  is  one  in  which  the  whole  table  is  a 
warm-water  container,  and  the  only  movement  required  one  that  will  raise  the  body 
and  lower  the  feet,  or  vice  versa. 

Whether  the  operating  table  shall  have  a  white  enameled,  or  glass  or  gun 
metal  or  bronze  top,  is  rather  a  question  of  taste.  Perhaps  the  top  made  of  cast 
steel  with  baked  white  enamel — that  new  form  of  table  top  that  seems  now  to  be 
fashionable — may  be  finally  agreed  upon  as  the  most  easily  cleaned  as  well  as  the 
most  durable  top.  Glass  is  more  easily  broken,  but  it  is  more  easily  kept  in  good 
condition,  and  it  certainly  gives  a  comely  appearance  to  the  table.     Gun  metal, 


EQUIPMENT    OK   THK    Ol'KKATIXG-ROOM 


209 


steel,  and  brass  are  eventually  marred  by  contact  with  acids  and  blood,  but  any  of 
these  tops  will  give  satisfaction,  and  the  question  of  which  one  shall  be  used  is 
hardly  worthy  of  serious  discussion. 

Whatever  table  is  used  there  ought  to  be  large  ball-bearing  rubber-tired  wheels, 
with  a  locking  device  that  will  hold  them  absolutely  when  the  table  is  in  use.  It 
is  extremely  desirable  to  have  good  wheels,  because  in  most  modern  hospitals 
patients  are  anesthetized  on  the  operating  tabic  itself,  so  that  it  will  be  unnecessary 
to  drag  them  about  from  the  stretcher  to  the  table.  It  is  quite  as  necessary,  how- 
ever, to  have  an  attachment  that  will  lock  the  wheels,  so  that  the  table  will  not 
move  about  under  the  surgeon's  manipulations. 


A 


X 


Fig.  Ill— Shelf  rack. 

Figure  109  shows  a  Hartley  table  in  the  Trendelenburg  position.  A  glance 
at  the  shoulder  braces  will  indicate  the  defect  pointed  out  above.  The  same  table 
is  also  shown  in  position  for  kidney  work  (Fig.  110). 

Shelf  Rack. —  The  next  most  important  piece  of  furniture  in  the  operating-room 
is  the  shelf  rack,  shown  in  Fig.  111. 

This  rack  is  made  of  two  pieces  of  gas  pipe,  white  enameled.  5  feet  apart, 
connected  by  shelving  of  heavy  plate  glass.  The  feet  are  shod  with  rubber  lips. 
This  shelf  usually  contains  the  various  powders,  catgut  in  its  various  forms,  some 


210 


EQUIPMENT    OF    THE    HOSPITAL 


I 


I 


f! 


Fig.  112. — Instrument  tray  stand. 


Fig.  113. — Drum  stand. 

few  solutions  in  small  quantities,  and  jars  containing  gloves,  iodoform  gauze  wrapped 
in  oiled  paper,  plaster-of-Paris  bandages,  adhesive  rolls,  and  odds  and  ends  of  opera- 
tive procedure. 


EQUIPMENT   OF   THE   OPERATING-ROOM 


211 


Instrument  Tray  Stand. — The  instrument  tray  stand  is  indicated  in  Fig.  112. 
This  is  merely  a  stand  on  wheels,  made  of  four  tubular,  white  enameled  legs,  joined 
by  enameled  brass  angle  iron  at  the  top;  and  another  section  of  the  same,  14  inches 
lower  down,  with  angles  made  so  that  the  instrument  trays  set  into  their  respect- 
ive places  securely.  The  whole  table  is  36  inches  high,  43i-  inches  long,  and  11  f 
inches  wide.  The  instrument  tray  that  belongs  to  this  stand  is  made  of  perforated 
metal  of  any  kind,  preferably  aluminum,  because  of  its  non-corrosiveness.  The 
objection  to  the  instrument  tray  is.  in- 
ability to  find  a  handle  that  will  not 
heat,  or  that  will  cool  quickly;  but  this 
objection  is  common  in  all  the  makes, 
and  is  overcome  by  the  use  of  metal 
handles,  made  in  the  shape  of  retractors. 
The  tray  handles  are  picked  up  with 
them. 


Fig.  114.— Sponge  rack. 


Fig.  115. — Irrigator  cart. 


Drum  Stands.- -Most  modem  hospitals  use  their  sponges,  packing,  and  various 
dressings  directly  out  of  laparotomy  drums  in  which  they  have  beeu  sterilized. 
The  stand  for  these  drums  operated  by  foot-pedal  is  shown  in  Fig.  113.  This 
stand  was  designed  for  the  New  York  City  Hospital,  and  is  a  most  convenient 
and  accessary  piece  of  operating-room  furniture.  The  table  shown  in  connection 
with  the  stand  is  not  necessary,  and  serves  to  render  the  whole  piece  of  furniture 


212 


EQUIPMENT    OF   THE    HOSPITAL 


cumbersome  and  awkward  to  handle.  A  much  smaller,  table  upon  which  to  handle 
the  dressings  will  answer  every  purpose,  and,  being  independent  of  the  drum  stand, 
can  be  moved  readily,  and  the  whole  equipment  will  be  much  more  convenient  for 
that  reason.  The  drums  themselves  are  circular  in  shape,  10§  inches  high,  14  inches 
in  diameter,  and  operate  by  means  of  a  triangle  fastened  into  the  top,  which  hangs 
in  the  arm  extension  of  the  foot-pedal. 

The  fastening  device  is  a  staple  and  hasp  that  may  be  locked  by  a  padlock. 
The  circular  band  of  metal  around  the  top  and  another  around  the  bottom,  per- 
forated to  fit  similar  perforations  in  the  drum  itself,  serve  to  open  and  close  the 
drum  as  it  enters  and  is  taken  from  the  sterilizer. 


Fig.  116. — Arm  immersion  stand. 

The  electric  drum,  made  similar  to  the  ordinary  drum,  but  13|  inches  high  in- 
stead of  10^  inches,  containing  electric-heating  coils  on  the  inside,  and  designed 
for  St.  Luke's  Hospital,  New  York,  seems  to  be  a  superfluous  piece  of  apparatus. 
The  coils  soon  burn  out,  and  the  utensil  is  rendered  useless. 

Sponge  Rack. — Figure  114  shows  the  best  style  of  sponge  rack  for  operating- 
room  use.  It  consists  of  a  standard  mounted  on  four  feet,  60  inches  high,  with 
three  horizontal  bars,  40  inches  long,  14  inches  apart,  containing  hooks  2  inches 
apart.  There  must  be  ten  hooks  on  each  side.  This  sponge  rack  is  designed  by 
the  Michael  Reese  Hospital,  especially  with  reference  to  the  make-up  of  the  drums, 
described  on  page  352  in  the  section  on  Operation. 

Irrigator  Cart. — Figure  115  shows  an  operating-room  irrigator  cart  designed  for 
the  Michael  Reese  Hospita.l    A  worm  gear  in  the  telescope  upright  raises  and 


EQ1  IPMENT   OF  THE   OPERATING-ROOM 


213 


lowers  the  irrigator  jars,  and  the  mechanism  is  on  wheels,  so  thai  it  can  be  moved 
readily.  It  is  perhaps  the  best  irrigator  arrangement  for  general  use  in  the  hospital, 
as  well  as  for  the  operating-rooms. 

Instrument  Table. — The  instrument  table  for  the  surgeons'  use  is  merely  an 
extension  of  the  principle  of  the  ordinary  bedside  table.  Instead  of  special  fittings 
this  table  may  rest  in  a  socket  designed  for  that  purpose  as  a  part  of  the  table. 
There  are  no  advantages  in  any  particular  make. 


B 


Fig.  117. — Solution  rack. 


Arm  Immersion  Stand.—  The  arm  immersion  stand  for  operating-room  use  is 
shown  in  Fig.  116,  in  connection  with  the  solution  basins.  This  combination  of 
basins  and  stand  is  to  lie  preferred  to  the  two  separated,  since  the  immersion  stand 
in  this  case  takes  up  no  more  room  and  serves  every  good  purpose.  It  is  made  of 
any  metal  that  will  permit  a  permanenl  burning  in  of  white  enamel.  In  most  of 
them  the  enamel  soon  chips  and  the  metal  rusts,  a  most  undesirable  thing  where 
asepsis  and  cleanliness  are  prerequisites. 

Solution  Rack.— A  somewhat  cumbersome  and  quite  costly  piece  of  mechanism, 


214 


EQUIPMENT   OF   THE    HOSPITAL 


yet  one  that  will  oftentimes  serve  a  very  good  purpose,  is  the  solution  rack,  shown 
in  Fig.  117.  The  purpose  of  this  rack  is  to  contain  various  solutions  in  large 
quantities.  It  was  designed  for  battleship  use  in  the  United  States  Navy,  and  is 
so  arranged  that  the  sections  can  be  turned  upside  down,  or  the  upper  tier  of  bottles 
can  be  changed  to  the  lower  tier  by  release  of  a  spring  and  with  simple  hand  move- 
ment.    It  is  not  worth  the  price  asked  for  it  for  land  hospital  uses. 


Fig.  118. — Solution  rack. 

Goose-neck  Reflector.— Figure  119  shows  a  goose-neck  flexible  reflector  light 
for  operating-room  use,  designed  by  Dr.  Greensf elder  for  the  Michael  Reese  Hospi- 
tal. The  advantage  of  this  particular  style  of  reflector  is  mobility  and  the  flexi- 
bility of  its  light  to  any  point  for  a  survey  of  the  field.  It  is  made  by  the  Hos- 
pital Supply  Co. 

Operating-room  Sinks.— There  is  very  little  to  be  said  about  the  operating- 
room  sinks,  excepting  that  they  shall  have  abundant  shelf  room  beside  the  basins, 
to  contain  the  jars  of  sterile  brushes,  nail  files,  Schleicht  or  marble-dust  soap,  and 
green  soap.  The  faucet  connections  may  be  either  knee,  elbow,  or  foot  move- 
ment, but,  in  either  event,  must  be  so  connected  that  the  flow  of  water,  both  hot 


EQUIPMENT   OP   THE   OPERATING-ROOM 


215 


and  eokl,  must  immediately  stop  with  the  removal  of  the  elbow  or  foot.  In  a 
good  many  hospitals,  where  there  is  a  knee  action,  the  movement  of  the  knee  starts 
the  How,  hut  docs  not  stop  it.  In  nearly  every  hospital  the  wasli  water  in  the 
operating-room  is  sterile,  which  means  that  it  has  cost  fuel  to  make  it  ready,  and 
fuel  eoMs  money.  Where  the  movement  is  of  this  character  il  i-  the  hal.it  of 
surgeons  to  start  the  water  and  let  it  run,  and  sometimes  it  is  left  running  dur- 
ing the  whole  of  an  operation,  which  will 
always  mean  a  drain  on  the  coal  pile.  Sur- 
geons, as  a  rule,  object  to  mechanism  in 
which  the  water  stops  running  with  the 
removal  of  pressure.  The  reason  they  give 
is  that  it  requires  too  much  attention  to 
attain  the  right  temperature  of  water;  this, 
however,  is  merely  an  inconvenience  to  them 
and  requires  a  little  more  of  their  atten- 
tion, ,  while  the  constant  flow  type  of  the 
faucet  means  a  constant  drain  on  the  coal 
pile,  and  this,  repeated  throughout  the  house, 
runs  into  money  rapidly. 

Whether  the  action  of  the  faucet  shall  be 
by  movement  of  the  elbow,  the  knee,  or 
the  foot  is  rather  a  question  of  taste  and 
convenience;  the  foot  action  answers  every 
purpose,  with  the  pedal  low  enough  to  rest 
on  the  floor,  and  thus  give  a  fulcrum  to 
the  foot  when  the  pedal  is  pressed  upon. 
There  are  knee  action,  spring  faucets  with 
some  of  the  newer  plumbing,  but  they  do 
not  act  smoothly,  and  surgeons  object  to 
them  because  too  delicate  adjustment  is 
required  to  obtain  the  right  temperature  of 
water. 

Soap  Containers. — There  is  a  universal 
demand  for  a  green-soap  container,  fixed  to 
the  wall  above  the  basin,  operated  by  foot  or 
knee  action,  that  will  release  the  green-soap 
solution  in  a  practical,  convenient  way. 
There  seems  to  be  no  such  device  on  the 
market.  There  are  a  number  of  these  soap 
containers  offered  for  sale,  but  they  soon  get 
out  of  order,  and  after  the  soap  has  been  in 
them  for  a  few  hours  they  clog  and  fail  to 
operate.  Such  a  piece  of  apparatus  of  a 
workable  sort,  practical  in  its  operation  and  that  would  not  get  out  of  order, 
would  fill  a  much-needed  place  in  operating-  and  dressing-rooms. 

Instrument  Cabinet.-  A  very  necessary  piece  of  furniture,  not  for  the  operating- 
room  itself,  but  that  musl  be  nearby,  is  the  instrumenl  cabinet.  Figure  120  shows 
such  a  cabinet  of  practical  design,  easily  cleaned,  and  well  lighted.  The  beveled 
top  and  back  are  of  sheet  metal,  white  enameled,  and  the  door  frames  and  front 
are  of  angle-iron  white  enameled.  The  shelves  and  doors  and  ends  are  of  plate  glass. 
giving  at  all  times  a  full  view  of  the  instrument-  in  the  cabinet,  and  making  it  cer- 


Fig.  119. — Goose-neck  reflector. 


216 


EQUIPMENT    OF   THE    HOSPITAL 


tain  that  dirt  and  dust  can  be  readily  seen,  and  hence  the  cabinet  will  be  kept 
clean. 

It  does  not  seem  desirable  to  have  these  instrument  cabinets  very  large.  The 
one  in  the  cut  is  72  inches  wide  over  all  and  84  inches  from  the  peak  of  the  beveled 
top  to  the  floor.  It  would  seem  preferable  to  have  more  than  one  cabinet  rather 
than  a  larger  one  in  one  piece  because  of  the  difficulty  in  moving,  and  also  because 
there  will  rarely  be  a  location  where  a  greater  space  than  this  can  be  well  lighted. 
It  will,  of  course,  be  necessary  to  have  an  excellent  lock  on  all  instrument  cabinets, 
preferably  one  in  which  the  turning  of  the  key  will  release  top  and  bottom  plunge 
rods,  so  that  the  cabinet  door  cannot  be  pried  open  easily.     The  instrument 


Fig.  120. — Instrument  cabinet. 


cabinet  should  be  kept  at  a  distance  from  the  operating-room  itself  and  from  the 
sterilizing  room,  so  that  the  instruments  will  not  come  in  contact  with  the  moisture 
and  steam  incident  to  sterilization  and  the  use  of  hot  sterilizer  instruments  in  the 
operating-rooms. 

Every  cabinet  should  contain  a  hygrometer,  or  moisture  gauge,  and  these  gauges 
should  be  inspected  frequently  and  heeded,  in  order  that  the  instruments  may  be 
kept  dry  and  free  from  rust. 

Purely  Technical  Apparatus. — There  are  certain  pieces  of  apparatus  that  do 
not  properly  come  under  the  head  of  furnishings,  and  are  not  necessarily  a  part 
of  the  equipment  of  the  operating-room,  apparatus  that  might  be  classed  as  instru- 


EQUIPMENT    OF    THE    OPERATING-ROOM 


217 


ments  perhaps,  but  some  of  these  things  are  so  common  in  the  operating-room  of 
to-day  that,  by  stretching  a  point,  we  may  call  them  a  part  of  the  mechanical 
equipment.     Some  of  these  things  are: 

The  gas  anesthetizing  apparatus,  bone  drill,  cautery  machine,  and  electric 
battery  designed  for  lighting  cystoscopic  lamps. 

Anesthetizing  Apparatus. — The  anesthetizing  apparatus,  for  the  giving  of  ni- 
trous oxid  gas  over  long  periods  of  time  in  certain  classes  of  operative  cases,  is  a 
very  important  mechanism.  Figure  121  shows  this  apparatus,  designed  by  the 
Michael  Reese  Hospital,  in  use  in  that  institution  for  the  past  four  years.     Another 


Tip,.  121. — Apparatus  for  administering  nitrous  oxid  gas. 


design  for  the  same  purpose,  and  quite  as  efficient  in  its  operation,  has  been  made 
by  the  Teter  Manufacturing  Co.,  of  Cleveland,  Ohio.  The  Michael  Reese  appara- 
tus has  never  been  placed  on  the  market,  hut  is  made  on  order  by  the  Chicago  Sur- 
gical and  Electrical  ( !o.,  <  Chicago.  The  mechanism  consists  of  a  stand  with  double 
arms  at  the  top.  ( )n  one  side  are  the  two  oxygen  tanks,  and  on  the  other  the  nitrous 
oxiil  tanks.  On  each  side,  and  between  the  tanks  and  the  upright  of  the  stand,  is 
a  gas-bag,  one  to  contain  nitrous  oxid  gas  and  the  other  oxygen.  Valves  are  placed 
at  various  points,  by  means  of  which  the  gas  or  oxygen  is  released  into  the  bag. 
There  are  several  varieties  of  the  bag  used;  that  made  by  the  Teter  Manufacturing 
Co.,  of  pure  gum  with  t  wine-net  covering,  is  the  besl .  as  it  is  elastic,  and  either  the 


218 


EQUIPMENT    OF   THE    HOSPITAL 


oxygen  or  nitrous  oxid  can  be  kept  under  pressure,  so  that  it  can  be  paid  to  the 
patient  as  required.  There  is  a  5-foot  tube  of  woven  silk  with  rubber  lining  lead- 
ing from  the  tank  to  the  face-mask.  This  tube  is  kept  expanded  by  wire  coils 
inside.  The  face-mask  used  is  a  patented  article,  sold  by  the  S.  S.  White  Dental 
Manufacturing  Co.,  the  chief  feature  of  which  is  a  rubber  air-cushion  rim  that  fits 
tightly  about  the  face  of  the  patient,  so  that  all  outside  air  can  be  excluded. 

By  all  odds  the  chief  factor  in  gas  anesthetization  is  the  operator,  and  the 
giving  of  continuous  gas  is  so  much  of  a  modern  art  that  the  subject  will  be  treated 
in  detail  in  a  special  section  in  this  book,  under  the  heading  "  The  Anesthetic," 
from  the  administrative  standpoint. 

The  Cautery  Apparatus. — There  are  many  types  of  cautery  outfits  on  the 
market;  most  of  them  have  only  a  small  output  of  current,  sufficient  for  heating 
small  cautery  knives;  others  have  a  large  output  of  current,  only  suitable  for  the 
heaviest  electrodes. 


7HoloT -Generate. 


Fig.  122. — Cautery  apparatus. 

The  diagram  shown  herewith  (Fig.  122)  illustrates  a  cautery  apparatus  that  has 
a  wide  range  of  output,  making  it  possible  to  heat  anything  from  the  most  deli- 
cate cautery  knife  to  the  heaviest  electrode.  It  consists  of  a  small,  but  powerful, 
motor  generator,  which  changes  the  direct  current  into  alternating,  which  in  turn 
is  converted  through  an  induction  transformer  into  a  cautery  current.  Perfect 
control  of  the  output  is  afforded  by  means  of  two  wire  rheostats.  The  speed- 
controlling  rheostat  regulates  the  volume  of  the  alternating  current  before  it  reaches 
the  transformer.  When  no  current  is  taken  from  the  transformer  the  motor  runs 
freely,  and  does  not  consume  a  wasteful  amount  of  electricity.  This  method  of 
control  also  assures  a  full  efficiency  of  the  motor.  The  cautery-controlling  rheostat 
controls  the  current  supplied  to  the  cautery  electrode  from  the  transformer,  and 
has  a  range  of  current  wide  enough  to  heat  the  smallest  cautery  knife  as  well  as 
the  heaviest  electrode,  without  danger  to  the  one  or  fear  of  inefficiency  in  the  other. 


EQUIPMENT   OF   THE    OPERATING-HOOM 


519 


A  common  annoyance  with  heavy  cautery  electrodes  is  the  frequenl  breaking 
of  the  porcelain  tips  carrying  the  platinum  wire.  This  has  been  eliminated  l>y  u.-ing 
a  specially  made  lava  tip  instead  of  porcelain,  as  lava  is  extremely  tough  and 
practically  indestructible.  Lava  also  retains  heat  much  longer  than  porcelain, 
which  adds  to  the  efficiency  of  the  electrode.  In  coming  in  contact  with  blood  or 
any  other  liquid,  the  porcelain  tip  often  cracks  in  several  pieces  while  the  lava  tip 
remains  intact. 

The  base  of  the  cautery  apparatus  may  be  slate  or  marble,  as  they  cost  about 
the  same  and  are  equally  efficient.  Either  will  break  if  allowed  to  fall,  and.  a-  the 
apparatus  must  be  mounted  on  a  portable  carriage  for  use  anywhere  in  the  insti- 


Fig.  123. — Author's  bone  drill. 


tution,  it  is  necessary  to  choose  carefully  the  vehicle  on  which  to  set  it.  There 
should  be  large,  easy  running  wheels,  set  under  standards  spread  well  apart,  so  thai 
the  outfit  will  not  tip  over  easily. 

This  apparatus  operates  off  an  ordinary  lamp  outlet,  using  a  common  drop- 
cord  socket. 

Bone  Drill. — For  many  years — that  is,  ever  since  brain  surgery  became  a  scien- 
tific practice — surgeons  have  demanded  an  apparatus  that  would  give  them  more 
than  the  trephine,  an  apparatus  that  would  permit  the  making  of  large  bone  Baps, 
through  which  major  operations,  such  as  removal  of  tumors  ami  exploratory  exam- 
inations, may  be  done. 

There  are  three  forms  of  mechanism  offered  on  the  market  for  this  purpose: 


220 


EQUIPMENT    OF    THE    HOSPITAL 


One  is  the  hand  apparatus,  on  the  principle  of  the  brace  and  bit;  the  other  is  an 
adaptation,  with  modified  tools,  of  the  dental  drill ;  the  third  is  the  direct  employ- 
ment of  the  small  motor  with  the  tool  fastened  in  its  armature. 

The  end  desired  in  a  bone  drill  is  not  only  to  cut  through  the  bone,  but  to  do  so 
rapidly,  in  any  direction  and  in  such  a  way  that  the  dura  mater  will  not  be  wounded. 
Some  excellent  surgeons  prefer  one  of  the  instruments  suggested  and  some  another. 
Largely,  however,  it  has  been  a  matter  of  dexterity  and  skill  on  the  part  of  the  sur- 
geon himself,  and  he  has  divided  the  honors  with  his  instrument. 

Speaking  broadly,  none  of  the  three  mechanisms  does  the  work  well.  The 
brace  and  bit  mechanism  is  awkward,  works  slowly,  and  is  likely  to  plunge  down 
upon  the  dura,  even  in  the  most  delicate  handling. 


f  ti  TTT^ TTT 


m 


Fig.  124.— Tools  for  use  with  author's  bone  drill. 

The  second  mechanism  is  that  designed  by  Dr.  Hartley,  of  New  York.  It  is 
heavy,  too  difficult  to  control,  and  more  likely  even  than  the  hand  mechanism  to 
plunge  down  upon  the  dura,  because  the  operator  must  hold  the  eight-  or  ten-pound 
motor  up  against  his  chest  or  abdomen,  and  has  no  substantial  leverage  by  which  to 
delicately  control  his  pressure. 

The  dental  drill  is  very  much  too  small  an  affair,  either  to  drive  a  trephine  or 
any  tool  of  considerable  size.  The  author  has  designed  a  bone  drill,  shown  in  Fig. 
123,  that  some  of  the  surgeons  have  been  good  enough  to  say  meets  the  requirements 
of  brain  surgery.  It  has  been  necessary,  however,  to  design  also  a  number  of  tools 
different  from  those  heretofore  in  use,  a  group  of  which  are  shown  in  Fig.  124. 
This  apparatus  consists  of  a  half-horse,  shunl-wound,  direct-current  motor  that 
drives  belt-wise  the  rotating  drill  that  has  its  movement  in  the  covered  cable,  as 


EQUIPMENT   OF   THE   OPERATING-ROOM 


221 


shown  in  the  cut.    The  6-foot  cable  shown  in  the  hand  of  the  operator  is  made  of 

bundles  of  steel  wire  wrapped.  The  covering  is  a  flexible  steel  tubing  used  by  the 
electric  people  for  interior  conduit  work,  enclosed  in  a  leather  case  treated  with 
an  oil-asbestos  preparation  that  permits  its  sterilization.  The  tool  holder  a\  the 
end  of  the  drill  is  a  clamp  operated  by  the  finger,  in  which  a  turn  or  two  releases 
or  tightens  the  tool,  and  then-  is  a  shoulder  at  the  end  of  each  tool  that  fits  into  the 
end  of  the  clamp. 

There  is  no  new  principle  in  any  of  this  mechanism.     It  is  the  application  of 
a  large  number  of  old  principles  to  achieve  the  desired  result;  and  the  only  particular 


Fig.  125. — Examination  chair. 


in  which  this  apparatus  differs  from  others  is  the  increase  in  driving  power  of  the 
drill,  the  flexibility  and  workableness  of  the  moving  mechanism,  the  difference 
in  some  of  the  tools,  and  the  fact  that  the  shunt  winding  of  the  armature  allows  the 
operation  of  the  full  power  of  the  motor  on  cither  slow  or  fast  speed.  One  of  the 
surgeons  who  uses  this  drill  makes  three  trephine  openings,  forming  a  triangle, 
slips  a  flexible  steel  duck-bill  director  into  one  and  along  toward  another,  between 
the  dura  and  the  bone,  and  works  the  saw  above  the  director. 

The  Victor  Electric  Co.,  Chicago,  has  recently  put  on  the  market  a  very  excel- 
lent machine  that  wants  very  little  improvement,  namely,  a  good  hand-hold  in  the 


222 


EQUIPMENT    OF    THE    HOSPITAL 


tool  mechanism.  They  also  do  not  make  a  good  or  serviceable  variety  of  tools.  The 
machine  is  made  to  set  on  a  table,  which  is  not  the  best  arrangement,  since  very 
often  there  is  no  convenient  place  to  set  a  table.  The  author's  hand-hold  is  far 
better  than  theirs,  and  his  small  tower  on  wheels  is  more  adaptable  to  the  space  of 
an  operating-room.     Their  tool-clamp  method  is  better  than  his. 

Cystoscopic  Battery. — The  small  lights  in  the  cystoscope  and  proctoscope  are 
made  to  work  at  four  volts  direct  current.  Ordinarily,  operators  take  their  current 
for  these  lights  from  the  regular  lighting  circuit  in  the  institution,  using  a  rheostat 
to  lower  the  voltage.  Those  who  have  used  these  instruments  know  how  frequently 
their  lamps  burn  out  while  they  are  making  an  examination,  necessitating  the  remo- 
val of  the  instrument  constantly,  a  lot  of  pain,  the  insertion  of  new  lamps,  and  a 
second  introduction  of  the  scope,  with  additional  great  pain  and  loss  of  time.     The 


Eclipse  head  lamp  in  use. 


burning  out  of  these  lamps  is  due  to  irregularities  in  the  voltage  of  the  lighting 
circuit  itself.  The  scheme,  then,  is  to  provide  a  current  of  electricity  that  will 
light  these  small  lamps  up  to  their  maximum  voltage,  and  that  will,  under  no  cir- 
cumstances, permit  of  a  high  enough  voltage  to  burn  them  out.  The  author  has 
made  for  this  purpose  a  small  battery,  composed  of  6-1  ampere,  one  volt  dry  cells. 
The  cells  are  placed  in  a  box  connected  in  series,  and  a  simple  button  switch  is 
placed  on  the  top  of  the  box,  with  the  two  connections  at  the  side.  With  this 
mechanism  one  may  turn  the  switch  from  one  to  six  cells  (that  is,  from  one  to  six 
volts,  and  the  battery  is  not  capable  of  a  higher  voltage,  so  that  the  lamp  will 
under  no  circumstances  burn  out.  This  little  device  can  be  made  by  the  electrician 
on  the  corner,  and  it  has  given  great  satisfaction  to  the  genito-urinary  surgeons 
who  have  used  it. 


EQUIPMENT   OF   THE   OPERATING-ROOM 


223 


Special  Apparatus  for  Special  Departments.— In  the  eye  car,  nose,  and  throat 
operating-room,  or  in  the  case  of  the  small  hospital,  the  special  apparatus  that  will 
be  required  for  eye,  ear,  nose,  and  throat  operations  are  an  extension  light,  a  head 
lamp,  and  a  special  chair.     This  apparatus  need  not  be  expensive. 

Figure  125  illustrates  a  convenient,  inexpensive,  and  competent  examination 
chair,  and  one  that  will  do  very  nicely  for  the  simpler  operations  that  require  only 
local  anesthesia.  This  is  merely  a  strong  chair,  with  support  for  the  back  of  the 
head.  There  are  many  more  elaborate  chairs  than  this,  some  that  hold  the  head 
by  a  clamp  action  in  precisely  one  position.  Such  an  apparatus  is  not  only  costly. 
but  it  falls  far  short  of  the  purpose  intended,  in  that  the  effort  on  the  part  of  the 


Fifj.  V27. — Dressing  cabinet. 

patient  to  get  away  from  the  instrument  and  the  inflexibility  of  the  bead  supporl 
make  it  all  the  more  difficult  for  the  operator  to  keep,  the  head  where  he  wants  it. 
It  is  the  experience  of  nose  and  throat  men  that  the  patient  whose  head  rests  easily, 
and  without  a  clamp,  will  hold  still  much  better  than  one  whose  head  is  fixed 
immovably. 

Figure  12G  shows  the  eclipse  head  lamp,  which  has  perhaps  fewer  disadvantages 
and  more  advantages  than  mosi  others.  The  reflector  is  bell  shaped;  the  lamp  it-elf 
is  small,  by  comparison;  the  combination  allowing  the  light  to  lie  thrown  into  a 
rather  narrow  field  in  front  of  the  operator,  whether  it  be  the  field  of  operation  in 
a  deep  laparotomy  or  mastoid,  or  whether  it  be  the  examination  field  in  the  throat, 


224 


EQUIPMENT    OF   THE    HOSPITAL 


nose,  or  ear.  This  lamp  is  commonly  used  by  nose  and  throat  surgeons  in  the 
performance  of  tonsillectomy  and  the  removal  of  adenoids.  A  particular  advan- 
tageous feature  is  the  mechanism  of  the  head  piece,  which  is  formed  of  a  pad  of 
asbestos  felt.  Unfortunately,  the  cover  to  this  felt  asbestoid  is  made  of  a  cheap 
black-colored  cambric,  which  runs  when  the  operator  perspires.  This  may  be 
avoided  by  lightly  sewing  on  to  the  head  piece  a  band  of  oiled  silk.  This  lamp  may 
be  had  of  almost  any  of  the  surgical  supply  houses,  and  costs  about  $5. 

Dressing-rooms. — The  dressing-room  is  a  place  where  much  work  is  done,  but 
where  little  apparatus  need  be  used.     A  regular  operating  table  of  almost  any 


Fig.  128. — Dressing  carts. 

design,  or  a  gynecologic  chair,  may  be  used  for  the  patient.  Whichever  is  em- 
ployed, the  coverings  must  be  so  arranged  that  the  waters  of  irrigation  will  run 
immediately  into  a  basin  or  bucket  on  the  floor.  This  can  be  done  with  rubber  cloth, 
a  Kelly  pad,  or  a  Burr  bath  apparatus. 

The. most  important  article  of  furniture  in  the  dressing-room  is  the  dressing 
cabinet,  illustrated  in  Fig.  127.  The  drawers  of  this  cabinet  will  hold  practically 
all  the  details  of  any  dressing,  and  the  shelves  will  hold  the  solutions,  powders, 
syringes,  and  whatever  j  ars  may  be  required .  The  only  advantage  of  this  particular 
form  of  cabinet  is  in  the  large  number  of  drawers  it  contains  and  the  ease  of  access 
to  those  drawers. 


EQUIPMENT    OE    THE    OPERATING-ROOM 


225 


The  basins,  percolators,  and  general  furniture  are  practically  duplicates  of  those 
used  in  the  operating-rooms. 

Dressing  Carts. — One  of  the  handiest  pieces  of  dressing-room  apparatus,  al- 
though it  is  not  used  in  the  dressing-room  itself,  is  the  dressing  cart,  illustrated 
in  Fig.  128.  This  is  merely  the  three-wheeled  percolator  cart  \\  ith  worm  gear,  made 
by  the  Hospital  Supply  Co.  especially  for  the  Michael  Reese  Hospital,  and  chd  in- 
rated  by  the  author  by  the  addition  of  shelves,  as  indicated  in  the  illustration. 
The  percolators  may  be  filled  with  the  necessary  solutions;  the  turret  at  the  top 
may  be  filled  with  powders  and  whatever  solutions  or  drugs  are  usually  employed 
in  the  dressings;  one  of  the  shelves  may  contain  a  basin  to  be  used  for  catching  the 
waters  of  irrigation,  and  the  other  shelves  may  contain  instruments,  bandages. 


Fig.  129.— Gynecologic  table. 

adhesive  plaster,  gauze,  and  dressing  drum.  The  particular  advantage  of  this  cart 
over  others  that  are  offered  for  sale  is  in  its  ease  of  handling,  because  of  the  short- 
ness of  the  cart,  the  single  front  wheel,  and  the  movable  tongue.  The  cart  may 
he  wheeled  into  the  ward  or  into  a  private  room  for  the  dressing  of  a  patient  that 
cannot  be  taken  to  the  dressing-room  proper. 

Gynecologic  Table. —  In  the  gynecologic  dressing-room  the  only  feature  that  need  , 
be  mentioned  is  the  dressing-table  itself,  illustrated  in  Fig.  129.  This  dressing- 
table  is  simple  in  its  construction  and  design,  comparatively  inexpensive,  with 
enameled  metal  top  and  moving  mechanism  to  place  the  patient  in  any  of  the 
classic  dressing  positions.  The  step  on  the  side,  as  shown  in  the  illustration,  differs 
somewhat  from  most  tables,  in  which  the  step  is  at  the  foot  of  the  table,  and  this 
seems  to  be  a  desirable  arrangement  in  the  estimation  of  a  good  many  gynecologists. 

15 


EQUIPMENT  OF  THE  KITCHEN 

Ranges. — The  size  of  the  institution  and  the  consequent  size  of  the  kitchen 
will  make  very  little  difference  in  the  arrangement  of  the  kitchen  for  convenience. 
What  will  be  convenient  in  one  will  be  convenient  in  another,  and  what  will  tend 
toward  sanitation  and  cleanliness  in  the  one  will  tend  toward  the  same  virtues 
in  the  other.  By  all  means  the  ranges,  whatever  their  size  and  construction,  should 
be  in  the  middle  of  the  floor.  The  make  of  kitchen  ranges  is  not  a  matter  of  supreme 
importance.  Most  of  those  on  the  market  answer  the  purpose  intended.  The 
good  features  of  any  range  contemplate  the  concentration  of  heat  on  all  sides  of  the 
oven,  with  an  abundant  supply  of  heat  distributed  to  the  top  of  the  range. 

The  question  of  fuel  may  just  as  well  be  briefly  discussed  here,  because  the  con- 
struction of  the  ranges  will  depend  a  good  deal  on  the  kind  of  fuel  to  be  used.  In 
this  matter  there  is  hardly  a  choice.  Hard  coal,  when  it  can  be  had,  is  the  only  fuel 
for  kitchen  purposes.  Gas,  whether  it  be  artificial  or  natural,  is  far  too  expensive; 
soft  coal  is  too  dirty,  and  its  heat  power  is  too  low.  Some  illuminating  figures 
might  be  given  showing  the  relative  economy  of  gas  and  hard  coal.  In  round  figures, 
gas,  even  when  it  is  to  be  had  at  most  economic  prices,  will  cost  at  least  four  times 
as  much  as  hard  coal  in  any  central  part  of  this  country  and  give  less  satisfaction. 
The  exception  in  the  use  of  hard  coal  is  in  the  matter  of  broilers;  it  is  doubtful 
whether  coal  will  give  that  even  distribution  of  heat  for  broiling  purposes  neces- 
sary to  proper  preparation  of  the  food,  and  gas  seems  to  meet  these  requirements 
far  better.  Almost  any  of  the  broilers  and  toasters  on  the  market  will  meet  their 
several  requirements.  Of  course,  the  broiling  and  toasting  must  be  done  below  the 
fire,  and  there  will  be  a  considerable  economy  in  fuel  if  the  flame  burns  against  a 
heavy  steel  asbestos-backed  plate,  the  heat  radiating,  not  from  the  gas  itself,  but 
from  the  heated  plate  above.  When  this  mechanical  construction  is  employed 
the  evenness  of  the  heat  can  be  much  better  controlled  than  where  the  heat  of  the 
flame  itself  is  to  be  depended  on.  If  there  is  to  be  very  little  broiling  or  toasting, 
and  that  little  at  long  intervals,  the  heat  of  the  heavy  plate  will  require  too  much 
time  and  too  much  gas,  but  in  most  institutions  there  will  be  sufficient  work  to 
justify  the  heating  of  the  heavy  steel  plate  for  each  meal. 

There  ought  to  be  shelves  in  the  superstructure  of  all  ranges  for  pans,  spoons, 
forks,  and  kitchen  tools  generally  that  are  constantly  employed  at  the  stove.  If 
the  cook  can  reach  for  these  things  without  having  to  leave  the  front  of  the  range 
there  will  be  considerable  economy  in  time.  There  should  not  be  any  arrangement 
for  the  warming  of  plates  or  dishes  in  connection  with  the  ranges  except  in  a  very 
small  institution,  where  a  separate  dish  warmer  would  hardly  pay;  they  will  always 
be  subjected  to  grease  and  the  natural  soiling  processes  of  the  range  atmosphere. 

The  Kitchen  Table. — The  next  most  important  thing  in  the  kitchen  is  the  table, 
which  should  extend  at  least  the  length  of  the  range  and  broilers,  and  it  cannot  be 
made  too  substantial;  it  must  certainly  be  made  of  2-inch  stuff  for  the  top,  and  the 
best  are  made  of  2  by  4  inch  edge  grain  Georgia  pine  for  the  top.  These  two  by 
fours  are  planed  on  both  sides,  and  enough  of  them  are  laid  side  by  side  on  edge  to 
make  the  whole  top  of  the  table.  If  properly  made  there  are  no  cracks,  and  these 
pieces  can  be  bolted  so  tightly  together  that  they  make  practically  a  solid  top  4 

226 


EQUIPMENT    OF   THE    KITCHEN 


227 


inches  thick.  Of  course  there  will  be  drawers  for  keeping  all  sorts  of  range,  carving, 
and  serving  utensils.  The  drawers  should  not  continue  to  the  floor;  there  should 
he  sufficient  space  underneath  to  permit  mopping  and  cleaning;  besides  this,  cooks 
like  to  stand  close  to  the  table  when  they  are  working,  as  the  strain  on  the  back  will 
be  less,  and  if  there  is  no  place  under  the  bench  for  their  feet  they  cannot  stand 
close. 

Dish  Warmers. — In  serving  meals,  naturally  the  cook  and  his  assistants  will 
stand  between  the  table  and  the  range.     On  the  other  side  of  the  table  will  be  the 


Fig.  130. — Dish  warmer. 


serving  maids  or  men,  and  just  back  of  these  servers  is  a  place  for  the  dish-warming 
apparatus,  and  this  piece  of  mechanism  is  rather  an  important  one.  It  need  not 
be  complicated  in  any  way,  but  it  should  be  of  considerable  size,  large  enough  at 
least  to  hold  all  of  the  dishes  necessary  to  be  used  for  any  one  meal  in  all  those  por- 
tions of  the  house  for  which  the  food  is  to  be  served  in  the  dishes.  A  good  part  of 
the  institution  will  be  served  from  the  serving  rooms  on  the  floors,  and  the  food 
will  be  transported  in  food  boxes,  to  be  described  later. 

This  dish-warming  apparatus  consists  of  two  upright  metal  pieces,  preferably 
of  J-inch  sheet  steel  or  iron,  strengthened  with  upright  eye  beams.     Shelves  are 


228  EQUIPMENT   OF   THE    HOSPITAL 

placed  between  the  uprights,  made  also  of  sheet  metal,  supported  on  eye  beams, 
with  central  upright  supporters  made  of  eye  beams  if  necessary.  Each  one  of  these 
shelves  is  turned  down  at  the  front  and  back  edge  for  an  inch,  and  just  under  each 
shelf  will  be  a  sufficient  number  of  steam  coils  to  serve  the  purpose;  the  width  of 
the  mechanism  will  be  12  or  14  inches.  Figure  130  will  give  the  principal  points 
in  this  dish-warming  mechanism.  It  is  a  very  simple  affair  and  very  serviceable. 
The  back  and  front  can  be  closed  with  an  ordinary  duck  curtain,  and  nearly  all  the 
heat  will  be  retained  when  this  curtain  is  drawn.  It  will  be  only  necessary  to  turn 
on  the  steam  fifteen  or  twenty  minutes  before  the  dishes  are  to  be  used. 

Steam  Table. — Another  piece  of  mechanism  in  the  equipment  of  the  kitchen 
that  must  be  chosen  with  care  is  the  steam  table.  This  article  will  be  used  mostly 
for  cooking  cereals  over  night  and  during  the  day,  and  keeping  roasts  and  vegetables 
warm.  Almost  all  of  the  steam  tables  on  the  market  now  are  efficient  and  adequate 
to  do  any  work  called  for,  and  there  is  hardly  a  choice,  excepting  perhaps  in  the 
material,  finish,  and  the  arrangement  of  the  compartments.  The  steam  baths 
and  warming  apparatus  are  practically  the  same  in  all  of  the  makes,  so  that  in  buy- 
ing a  steam  table  there  are  practically  two  considerations  only:  first,  to  get  a  table 
large  enough  to  do  not  only  the  present  work,  but  in  anticipation  of  future  growth 
of  the  institution,  and  to  get  a  table  apportioned  in  regard  to  its  compartments, 
so  that  it  will  meet  the  requirements  intended.  Manufacturers  are  not  always  the 
best  judges  as  to  how  many  vegetable,  meat,  and  cereal  compartments  a  steam  table 
should  have,  and  the  purchaser  must  use  his  own  judgment.  The  second  considera- 
tion in  purchasing  a  steam  table  is  the  price,  and  that  will  depend  a  good  deal  on 
the  material  used  and  the  workmanlike  manner  in  which  the  table  is  put  together. 
We  must  remember  that  a  steam  table  is  intended  to  last  a  great  many  years — a 
generation — if  properly  made  and  properly  used,  so  it  would  be  false  economy  to 
select,  for  instance,  galvanized  iron  or  any  material  capable  of  corrosion,  when  a 
few  more  dollars  would  buy  the  best  heavy  copper. 

Dish  Washers. — If  the  dishes  used  by  the  nurses  and  interns  and  hospital  help 
are  sufficiently  numerous,  and  can  be  readily  assembled  at  one  point,  it  may  well 
be  economy  to  install  dish-washing  machinery.  In  hotels  this  can  readily  be  done 
because  the  dining-rooms  are  placed  together  and  all  the  dishes  placed  approxi- 
mately at  one  place;  there  is,  undoubtedly,  a  good  deal  of  economy  to  be  practised  in 
having  dish-washing  machinery  when  the  dishes  can  be  assembled  in  large  quan- 
tities. With  dish-washing  machinery  about  as  many  people  are  required  to  do  the 
work  as  where  it  is  done  by  hand,  but  there  is  an  immense  saving  in  the  time  occu- 
pied in  the  work,  and  the  people  who  are  charged  with  the  dish-washing  work  can 
then  go  to  some  other  occupation. 

In  a  dish  washer  there  are  two  or  three  fundamental  principles  to  be  observed. 
One  of  these  is  that  the  dishes  must  be  so  fastened  in  the  machinery  that  they  will 
not  move  about  and  break,  and  at  the  same  time  they  must  be  so  placed  that  the 
insides  as  well  as  the  outsides  can  be  thoroughly  washed.  Economy  of  space  for 
the  machine  is  important  because  oftentimes  there  is  not  a  great  deal  of  room  in 
the  scullery  for  the  machine;  the  mechanism  must  be  simple,  so  that  ordinary  dish 
washers  can  manipulate  it  without  danger  either  to  themselves  or  to  the  machinery, 
and  last,  but  by  no  means  least,  the  mechanism  must  be  of  such  character  that  water 
and  slop  and  steam  will  not  be  allowed  to  get  all  over  everything  in  the  room,  and 
there  must  be  economy  in  water  and,  more  especially,  in  soap. 

There  are  several  dish-washing  machines  on  the  market,  the  best  of  which,  at 
least  until  very  recently,  is  the  Insinger  machine,  made  by  the  Insinger  Co.,  of 
Philadelphia  (Fig.  131).     This  washer  answers  all  of  the  requirements;  it  has  two 


EQUIPMENT   OF   THE   KITCHEN 


_'_".! 


tanks,  each  of  which  is  operated  by  a  propeller,  driven  by  a  motor  placed  at  one  end 
of  flic  machine.  The  dishes  are  fastened  in  the  crate  so  thai  they  are  immovable, 
and  they  do  not  touch  one  another;  they  remain  stationary  during  the  whole  proc- 
ess, and  the  motion  comes  entirely  from  the  water,  which  is  propeller-driven  in 
the  tank.  The  dishes  are  first  placed  in  one  tank,  which  is  filled  with  water  at 
about  60°  or  70°  F.,  and  the  water  is  agitated  by  the  propeller  until  the  dishes 
are  practically  clean;  there  is  an  automatic  arm  working  from  above  that  lifts  tin- 
crate  out  of  the  cold  water  into  the  next  tank,  in  which  the  water  is  kept  at  the  boil- 
ing-point; again  the  process  of  violent  agitation  takes  place,  and  whatever  residue 
of  grease  remains  on  the  dishes  is  carried  away  and  they  are  thoroughly  cleaned. 


Fig.  131. — Insinger  dish-washing  machine. 


The  boiling-point  of  the  water  is  sufficient  to  sterilize  the  dishes,  and  it  makes  them 
so  hot  that  when  they  arc  again  lifted  out  by  the  automatic  hoist  they  dry  themselves 
thoroughly.  This  machine  is  made  in  several  sizes,  one  with  a  capacity  of  12,000 
pieces  per  hour,  another  with  a  capacity  of  5000  or  6000  per  hour,  and  there  are 
smaller  ones.  It  would  seem  that  any  place  that  is  not  large  enough  to  require  at 
least  a  5000  or  6000  capacity  machine  would  hardly  be  large  enough  to  justify  the 
installation  of  such  a  plant. 

With  this  particular  machine  the  breakage  is  extremely  small — in  fact,  a 
negligible  quantity — and  there  are  other  machines  that  break  a  great  many  dishes, 
This  machine  costs  more  than  most  of  the  others,  perhaps  10  or  15  per  cent,  more, 


230  EQUIPMENT   OF   THE    HOSPITAL 

but  the  saving  in  dishes  would  more  than  justify  the  additional  expenditure. 
Figure  130  shows  this  machine  with  the  motor  mechanism,  one  of  the  crates,  the 
two  tanks,  and  the  automatic  hoist. 

The  Blakeslee  machine  is  of  similar  type,  but  the  tanks  that  hold  the  water  are 
round  or  barrel  shaped,  and  the  water  enters  at  the  top,  from  the  sides,  causing  a 
whirlpool  of  water  to  pass  down  through  the  contents,  tossing  the  china  about  in 
the  tank,  rubbing  the  glaze  off,  and  breaking  some.  It  is  not  very  successful  in 
washing  cups. 

The  Hamilton  Lowe  machine  is  another  model  of  a  similar  type,  with  the  excep- 
tion that  it  has  the  square  tank,  and  the  water  goes  through  the  same' operation 
as  in  the  Blakeslee.  It  requires  a  good  deal  of  help,  and  the  baskets  that  the  china 
is  placed  in  have  to  be  raised  and  lowered  several  times  during  the  operation. 
Furthermore,  the  china  comes  in  contact  with  wire  baskets  and  metal,  which  rubs 
the  china  and  spoils  the  glaze,  an  expensive  operation  for  a  hotel  or  restaurant  or 
hospital  that  uses  high-class  table  ware. 

The  Garis-Cochrane  machine  was  placed  on  the  market  with  a  view  to  washing 
dishes  with  speed  and  economy.  In  this  machine  the  china  is  placed  in  wooden 
racks.  These  are  then  placed  in  the  machine,  several  racks  on  top  of  each  other. 
In  the  operation  of  the  machine  the  soapy  water  is  forced  through  a  pipe  with  a 
small  pump.  This  pipe  is  worked  on  a  spiral,  and  the  water  circulates  through  the 
tank  in  the  shape  of  a  cross.  At  the  end  of  each  arm  of  the  cross  there  is  a  T  with 
a  cap  on  the  end,  which  releases  itself,  allowing  the  water  to  pass  out  between  the 
T  and  the  cap,  making  a  circular  spray.  The  force  of  the  water  is  slight,  passing 
as  it  does  to  and  fro  across  the  tank,  washing  as  it  flows.  During  the  operation  the 
machine  is  kept  closed  to  prevent  the  water  from  splashing  on  the  floor.  Then  the 
pump  is  shut  down,  and  fresh  water  is  turned  on  from  the  faucet,  to  go  through  the 
same  pipe  and  through  the  same  operation  as  the  soap  water  has  done,  in  order  to 
rinse  the  dishes.  This  has  been  found  impractical,  as  there  is  not  force  enough  in 
the  water  to  rinse  the  dishes  properly.  Furthermore,  the  whole  operation  is  a  slow 
one  and  expensive  for  that  reason. 

The  Victor  machine,  which  has  lately  been  put  on  the  market  by  L.  A.  Haustet- 
ter,  of  Chicago,  an  old  hotel  steward,  is  perhaps  the  simplest  of  all  dish-washing 
machinery.  It  is  strong,  and  built  to  withstand  the  wear  and  tear  of  heavy,  con- 
stant work. 

There  are  two  water  levels  in  the  tank,  one  for  the  rinsing,  which  contains  clean 
water,  and  the  other  the  soap-suds  for  washing  and  removing  the  grease.  The  level 
of  the  rinsing  water  is  kept  at  a  higher  level,  by  an  automatic  feed  device,  than  the 
soap  water,  and  there  is  maintained  a  constant  flow  from  the  rinsing  to  the  soap 
tank,  as  over  a  dam,  thus  carrying  the  skum  and  grease  from  the  clean  to  the  soap 
side.  But  this  flow  continues  across  the  soap  tank,  forcing  the  grease  and  skum 
on  and  out  to  some  grease-catching  device,  to  be  destroyed  or  kept  for  rendering. 
There  are  two  centrifugal  pumps  run  by  a  motor,  one  pump  for  the  soap  water  and 
one  for  the  rinsing  water.  The  water  is  pumped  from  the  bottom  of  each  tank  into 
a  spraying  device  above,  and  the  water  is  used  over  and  over,  with  the  soap  and 
skum  constantly  going  over  the  dams  out  of  the  sphere  of  action.  Each  one  of 
these  spray  plates  contains  2000  i-inch  holes.  The  china  is  placed  in  wooden  baskets, 
having  no  metal,  that  do  not  move  while  in  operation.  As  one  rack  is  filled  it  is 
placed  in  the  machine  at  the  soap-water  end,  then  another  rack  is  filled  and  placed 
in  the  machine,  pushing  the  rack  previously  put  in  ahead.  This  operation  is  con- 
tinuous. 

Two  persons  are  engaged,  one  to  assemble  and  place  the  dishes  in  the  rack  and 


EQUIPMENT   OF   THE    KITCHEN 


231 


the  rack  into  the  machine,  and  another  to  take  away  and  distribute  those  that  are 
clean.     Since  the  rinsing  water  is  very  hot  the  dishes  dry  themselves  quickly. 

It  is  claimed  for  this  machine  that  it  is  not  only  more  rapid  in  action,  but  that 
the  water  and  soap  required  are  less  than  in  other  machines.  Figures  132  and 
133  show  the  mechanism  of  this  apparatus.  It  costs  a  little  more  than  any  of  the 
other  dish-washing  devices. 

Sinks. — The  kitchen  sinks  are  of  a  good  deal  of  importance.  Manufacturers 
have  tried  long  and  hard  to  find  a  material  that  would  wear  well.  There  are  a 
good  many  people  who  believe  that  wooden  sinks  are  the  best;  there  are  others 
who  like  porcelain;  and  even  a  larger  number  who  prefer  concrete;  slate  is  the  choice 


Victor  dish-washing  machine. 


of  others.  These  slate  slabs  should  be  not  less  than  1-*  inches  thick;  they  can  be 
fitted  tightly  by  rabbitting  the  bottom  with  the  sides  and  ends,  but  slate  will  not 
do  at  all  unless  it  is  bound  with  brass  or  nickeled  brass;  slate  is  not  a  very  hard  sub- 
stance, and,  unless  it  is  bound,  it  soon  wears  on  the  edges  and  chips.  There  is  a 
softness  about  slate  that  will  cause  fewer  broken  dishes  than  with  either  concrete 
or  porcelain.  Sinks  made  of  2-inch  cypress  wood,  and  bound  on  the  edges  with 
brass  or  even  steel,  are  inexpensive  and  very  durable;  if  the  segments  of  wood  .ire 
doweled  in  and  fastened  with  long  bolts  they  do  not  warp;  moreover,  the  wood  is 
so  soft  and  springy  that  dishes  sometimes  escape  destruction  when  they  fall. 

Soup-stock  Boiler. — One  of  the  most  important  articles  of  kitchen  equipment 
is  the  soup-stock  boiler.     Several  manufacturers  are  making  this  article  of  an 


232 


EQUIPMENT    OF    THE    HOSPITAL 


outer  and  inner  case  of  cast  steel  with  steam  coils  between,  and  with  a  steam  release 
valve  that  will  allow  the  live  steam  to  permeate  the  contents.  Both  these  casings 
are  made  very  heavy,  and  the  steam  coils  are  generally  inadequate  to  provide  a 
sufficient  quantity  of  heat  to  start  the  boiling  in  a  reasonable  time.  A  very  efficient 
pattern  of  this  mechanism  is  that  made  by  the  Wrought  Iron  Range  Co.,  of  St. 
Louis.  The  inside  of  the  mechanism  is  a  half-globe  of  polished  steel  in  one  piece, 
with  no  joints  or  connections  of  any  sort,  and  the  provision  for  steam  in  the  jacket 
is  sufficient  to  start  soup-stock  boiling  in  a  few  minutes  after  the  steam  is  turned  on. 
Vegetable  Peelers,  Meat  Cutters,  and  Bread  Slicers. — There  are  certain  labor- 
saving  mechanical  devices  in  the  kitchen  that  will  be  of  interest  only  in  large  insti- 
tutions. One  of  these  is  the  vegetable  peeler.  We  have  had  something  to  say  else- 
where about  the  economics  of  vegetable  peeling.     We  will  now  deal  only  with  the 


\  f 


Fig.  133. — Victor  dish-washing  machine;  side  view,  interior. 


devices  for  doing  the  work.  Potatoes,  carrots,  and  turnips  are  peeled  in  the  fol- 
lowing manner:  a  quantity,  according  to  the  size  of  the  device  and  the  number  of 
people  to  be  fed,  is  placed  in  a  hopper,  which  has  a  lining  grater  that  rotates  rapidly, 
either  by  motor  or  from  line  shaft.  A  stream  of  water  pours  onto  the  vegetables 
while  they  are  rotated  in  the  hopper.  The  work  is  not  evenly  done.  Sometimes 
a  vegetable  will  be  stuck,  so  that  it  doesn't  rotate  and  will  be  ground  away.  As  a 
rule,  however,  the  grinding  is  pretty  uniform,  though  the  eyes  of  the  potatoes  are 
not  taken  out.  There  are  several  manufacturers  of  this  device,  and  each  claims 
for  his  mechanism  all  sorts  of  virtues  as  to  time  and  economy  in  operation.  Most 
of  these  claims  are  not  borne  out  by  the  facts,  and  it  may  be  very  safely  doubted 
whether  there  is  much  saving,  either  in  time  or  money,  in  the  present  makes  of 
vegetable  peelers.     The  only  part  of  the  mechanism  that  permits  of  the  choice 


EQUIPMENT    OF    THE    KITCHKN 


233 


between  the  various  makes  of  machine  is  the  grating  device.  The  Franklin  Company 
use  a  thin  metal  prater  that  has  to  be  renewed  about  once  a  month,  and  each  renewal 
costs  $6.  This  machine  is,  to  all  intents  and  purposes,  worthless.  Other  manu- 
facturers use  a  carborundum  grater,  that  is,  fine  particles  of  carborundum  fused 
into  a  cylinder  of  cast  steel.  Carborundum  is  extremely  hard,  and  the  grater  is, 
therefore,  very  durable.  Perhaps  the  best  manufacture  of  this  device  is  shown  in 
Fig.  134,  made  by  the  N.  R.  Streeter  Co.,  of  Rochester,  N.  Y. 

The  same  company  makes  a  meat  sheer,  shown  in  Fig.  135.  It  has  an  adjusting 
device  for  fixing  different  cuts  of  meat.  This  machine  is  used  more  especially 
for  cutting  dried  beef  and  bacon.  It  is  rather  an  expensive  machine,  but  very 
satisfactory,  and  it  may  be  safely  doubted  whether  it  is  not  an  actual  economy, 


Fig.  134. — Power  peeler  with  motor  stand  and  guard. 

because  thin  sliced  bacon  and  chipped  beef  are  not  only  nicer,  but  since  we  all  eat 
so  much  with  our  eyes  it  may  be  safely  said  that  about  so  many  slices  of  meat  will 
be  eaten,  whether  they  are  thin  or  thick,  and  the  thinner  they  are  the  farther  they 
will  go.  The  working  parts  of  this  device  are  rather  easily  cleaned,  and  it  need  not 
give  any  special  trouble. 

There  is  almost  nothing  to  be  said  about  a  bread  slicer.  There  are  any  number 
of  makes  on  the  market,  some  of  them  elaborate,  made  of  castings  with  self-feeding 
devices,  and  expensive.  Others  are  made  of  wood,  like  a  fanner's  ordinary  feed 
chopper,  and  the  one  that  should  be  used  will  depend  a  good  ileal  on  the  amount  of 
work  to  be  done.  The  principle  thing  to  consider  is  the  safety  of  the  device. 
Maids  seem  to  forget  about  their  ringers  when  they  are  in  a  hurry  slicing  bread,  and, 


234 


EQUIPMENT    OF    THE    HOSPITAL 


unless  the  device  is  "fool-proof,"  there  will  be  a  good  many  accidents.      Figure 
136  shows  one  of  these  rather  elaborately  made  devices. 


Fig.  135. — Meat  slicer. 


Fig.  136.— Bread  slicer. 

Vegetable  Cooker. — Preliminary  to  a  discussion  of  mechanism  in  which  to  cook 
vegetables,  let  us  think  briefly  of  the  requirements  in  vegetable  cooking  and  of  the 


KQIII'MI'.NT    OF    TIIK    KITCHF.X 


235 


chemic  changes  that  occur  when  vegetables  arc  cooked.  We  cook  vegetables 
in  one  of  two  ways,  either  in  boiling  water  or  by  means  of  steam,  and,  usually 
speaking,  we  cook  vegetables  until  they  are  soft.  When  we  cook  them  in  wati  r 
we  do  so  at  a  temperature  of  212°  F.,  that  is,  the  boiling-point  of  water,  and  one  of 
the  peculiar  physical  characteristics  of  water  when  it  is  boiling  is  to  take  out  of 
meat  or  vegetables  that  are  cooking  in  it  certain  of  their  extracts  and  soluble  constit- 
uents. If  we  boil  meat  long  enough  in  water  we  remove  nearly  all  of  its  extracts 
and  nutrient  properties — its  fats,  myocins,  ami  even  its  taste — so  that  at  the  end 
of  four  or  five  hours  of  boiling  one  will  hardly  be  able  to  distinguish  between  mutton 
and  beef,  and  we  use  the  water  in  which  this  meat  is  boiled  as  a  soup  stock,  and  ex- 
pect it  to  contain  practically  all  the  juices  formerly  held  in  the  meat. 

Now,  when  we  boil  vegetables  in  water  we 
perform  practically  the  same  office.  For  in- 
stance, with  potatoes  we  not  only  coagulate  the 
starches,  but  we  remove  most  of  the  protein  of 
the  potato  if  it  is  cooked  long  enough,  and  a 
well-boiled  potato,  especially  if  the  jacket  has 
been  removed,  has  almost  nothing  left  but  starch. 
The  peeling  serves  to  hold  these  nutrient  proteins 
for  a  much  longer  time,  but  eventually  the  peel 
comes  off  too,  and  with  it  the  protein  zone  on 
the  outside.  The  same  may  be  considered  true 
of  beans,  peas,  corn,  asparagus,  and  even  the 
leaf  vegetables,  such  as  spinach,  cabbage,  and 
cauliflower. 

The  ideal  way  to  cook  vegetables  is  in  the  so- 
called  tireless  cooker,  but  this,  of  course,  cannot 
be  done  for  a  large  institution.  The  most  de- 
licious navy  beans  can  be  prepared  in  the  Dutch 
oven,  in  which  the  vegetable  is  practically  sealed 
during  the  whole  process  of  cooking,  and  not 
only  the  juices,  but  the  taste,  is  retained.  Such 
a  device  is  not  practicable  for  the  large  quantities 
of  food  used  in  an  institution,  but  there  must 
be  a  substitute. 

Nearly  all  vegetables,  especially  when  fresh, 
contain  a  sufficient  amount  of  water  in  which 
to  cook   themselves,  and    they  need    practically 

only  the  direct  application  of  heat  to  prepare  them  for  the  table.  The  best  form 
of  heat  is  steam,  a  few  degrees  higher  than  the  boiling-point  of  water,  and,  if  this  is 
applied  carefully,  almost  no  part  of  the  vegetable,  not  even  the  taste  and  odor, 
need  be  lost,  and  all  of  its  chemic  virtues  as  a  nutrient  retained. 

Figure  137  shows  rather  a  new  device  for  cooking  vegetables  by  means  of  high- 
temperature  steam,  applicable  to  institutions  of  any  sort.  It  is  made  by  the 
Boin  Steel  Range  Co.,  Cleveland,  The  illustration  shows  three  separate  independ- 
ent cookers;  each  section  measures  IS  inches  wide,  22'  inches  deep,  and  0  inches 
high  inside,  and  each  section  is  provided  with  a  perforated  galvanized-iron  steam 
basket.  Instead  of  the  basket  there  is  also  a  removable  perforated  shelf  to  fit 
any  of  the  sections,  to  cook,  for  instance,  whole  potatoes.  These  sections  are 
made  wholly  independent  of  each  other,  and.  instead  of  three  sections  in  a  device. 
there  may  be  two,  or  one,  or  five,  as  the  institution  may  require.     The  sections 


Fig.  137. 


vegetable 


236  EQUIPMENT    OP   THE    HOSPITAL 

are  made  of  cast  iron,  seamless,  and  each  is  fitted  with  a  steam-tight  door.  There 
are  check  valves  on  both  vent  and  drain  connections,  to  prevent  the  mixing  of 
odors  or  flavors,  and  it  is  a  matter  of  experience  to  determine  just  how  much  steam 
shall  be  let  in,  and  to  what  extent  the  vent  pipe  shall  be  opened,  to  insure  a  perfect 
cooking  of  the  vegetable  without  loss  of  its  taste  and  odor  or  any  of  its  chemic 
nutrient  properties. 

In  an  era  that  is  now  rapidly  approaching  it  will  be  necessary  for  the  dietitian 
to  set  on  the  patient's  tray  a  certain  quantity  of  nutriment  that  has  been  previously 
definitely  figured  out  on  a  basis  of  the  raw  material  employed,  and  when  that  day 
comes  the  dietitian  will  have  to  take  into  consideration  all  the  delicate  chemic 
changes  that  take  place  when  heat  is  applied  to  the  article  to  be  cooked.  In  our 
present  state  of  ignorance  as  to  the  finer  chemic  changes  that  occur  during  the 
processes  of  cooking  we  are  wasting  much,  and  depriving  the  patient  of  some  of  the 
most  highly  nutritive  products  that  the  food  article  contains.  Let  us  prosecute 
this  thought  just  one  step  with  a  view  to  illustrate  the  point.  We  know,  of  course, 
that  the  human  assimilative  mechanism  can  master  the  animal  proteins  in  meat, 
and  we  know  that  the  human  digestive  process  can  assimilate  such  vegetable 
proteins  as  occur  in  the  legumes,  beans,  peas,  and  lentils,  but  we  know  also  that 
wheat  bran  contains  a  large  quantity  of  vegetable  protein  that  is  utterly  useless  to 
the  human  economy.  When  the  chemist  is  asked  why  this  is  true,  he  will  say  that 
the  protein  of  wheat  bran  is  enveloped  in  a  cellulose  insoluble  in  any  of  the  human 
gastric  juices,  and  he  will  tell  us  that  the  cow,  horse,  hog,  rabbit,  and  other  of  the 
lower  animals  can  assimilate  the  proteins  of  wheat  bran  because  of  certain  bacterial 
action  that  occurs  at  some  point  along  the  alimentary  tract,  as,  for  instance,  the 
large  cecum  in  the  rabbit,  during  the  activities  of  which  the  cellulose  envelope  is 
broken  down  and  the  protein  released  for  assimilation. 

The  main  purpose  in  cooking  food  is  to  make  it  more  agreeable  to  the  taste, 
because  the  cooking  process  releases  many  of  the  chemic  constituents;  cooking  also 
softens  most  vegetables  and  makes  them  easier  to  eat;  but  it  is  not  necessary  or 
desirable  to  destroy  their  form,  one  of  the  appetizing  features  of  food,  nor  is  it 
desirable  to  separate  the  parts  of  a  vegetable.  We  must  take  these  things  into  con- 
sideration in  cooking,  and,  therefore,  whatever  devices  we  use,  they  must  serve  the 
ulterior  purposes,  and  a  slow  cooking  without  water  is  the  best. 

Coffee  and  Tea  Urns. — Coffee  and  tea  urns  are  a  makeshift  at  best,  and,  as 
they  are  built  for  restaurants,  hotels,  and  institutions,  they  are  merely  a  concession, 
and  the  best  substitute  in  consideration  of  the  great  amount  of  coffee  and  tea  to  be 
prepared. 

The  ideal  way  to  prepare  these  beverages  is  in  small  individual  brewers.  For 
private  patients  at  least  tea  ought  always  to  be  brewed  in  individual  pots;  and,  in 
the  case  of  coffee  for  private  patients,  a  sufficient  quantity  should  be  made  in  a 
small  percolator  or  coffee-pot,  to  serve  a  small  number  of  patients  who  are  to  have 
their  meals  at  the  same  time,  on  the  same  floor,  or  in  the  same  pavilion,  so  that  the 
beverage  can  be  served  hot  and  fresh;  in  no  other  way  is  it  possible  to  serve  coffee 
that  will  be  satisfactory  to  people  of  refinement  and  wealth,  who  are  accustomed  to 
properly  served  things  in  their  own  homes. 

For  private  ward  and  ward  patients,  and  for  the  well  people  in  the  hospital,  who 
are  in  considerable  numbers,  it  will  always  be  necessary  to  make  both  coffee  and 
tea  in  the  large  commercial  urns  installed  for  the  purpose. 

There  is  hardly  a  choice  in  the  mechanisms  offered  on  the  market  as  coffee  and 
tea  urns.  They  are  practically  all  alike,  differing  only  in  workmanship,  finish, 
and  strength.     The  main  point  about  making  either  coffee  or  tea  in  these  large 


EQUIPMENT    OF   THE    KITCHEN'  237 

urns  is  to  make  it  properly  and  to  servo  it  fresh.  Manufacturers  generally  send 
printed  instructions  for  the  use  of  the  urns  they  sell,  and  the  details  of  these  instruc- 
tions are  generally  questions  of  taste  and  individual  idiosyncrasy. 

There  is  very  much  more  in  the  quality  of  the  coffee  and  tea  to  be  used,  and  in 
the  brewing,  than  there  is  in  the  mechanism  employed.  We  shall  have  a  good  deal 
to  say  in  regard  to  the  qualities  and  methods  of  purchase  of  coffees  and  tens  when  we 
come  to  the  section  on  Kitchen  Service  under  the  administrative  operations  of  the 
institution. 

An  urn  for  hot  water  installed  between  one  for  tea  and  one  for  coffee,  with  ample 
protective  valves  to  make  them  all  proof  against  explosion,  will  be  necessary  equip- 
ment. There  will  be  much  said  by  manufacturers  about  the  linings  and  jackets, 
but  there  is  hardly  a  choice  between  the  different  makes,  as  they  are  all  built  in 
about  the  same  way  and  out  of  the  same  materials. 

THE  DIET  KITCHEN 

Under  the  section  on  Operations  of  the  Hospital  we  shall  dwell  particularly 
on  the  efficiency  and  completeness  of  arrangements  for  transporting  food  to  patients, 
and  we  shall  likewise  discuss  the  serving  of  special  diets  throughout  the  institution, 
and  the  responsibilities  attendant  on  carrying  out  the  doctors'  orders  in  regard  to 
the  delivery  of  the  special  diets  to  the  patients  for  whom  they  are  devised,  and  upon 
the  efficiency  of  the  methods  employed  will  depend  the  reliability  with  which  an 
institution  can  undertake  to  give  special  diet.  All  these  things  go  back  funda- 
mentally to  the  diet  kitchen,  its  arrangement,  and  its  management. 

The  equipment  of  the  diet  kitchen  itself  is  a  simple  matter.  First,  it  should  be 
close  by  the  general  kitchen,  because,  whatever  the  plans  may  be  as  to  the  division 
of  work  between  the  two,  there  will  be  some  dishes,  generally  the  staples,  that 
must  be  prepared  in  the  general  kitchen  and  taken  thence  to  the  diet  kitchen  for 
distribution  in  the  form  of  made-up  trays. 

The  other  important  element  that  goes  to  make  up  a  first-class  diet  kitchen  is 
plenty  of  room,  because  many  trays  will  have  to  be  made  up  for  distribution,  no 
matter  how  many  serving  rooms  there  are  in  different  parts  of  the  house,  so  that  in 
the  diet  kitchen  there  must  be  plenty  of  shelf  room  on  which  to  set  trays,  and  these 
shelves  must  be  low  enough  to  be  convenient,  high  enough  to  be  easily  reached 
without  stooping,  and  with  room  enough  between  them  so  that  the  nurses  will  have 
freedom  of  action.  Without  all  these  factors  the  trays  will  be  slovenly  and  unap- 
petizingly  made  up. 

There  must,  of  course,  be  a  refrigerator,  preferably  one  with  several  compart- 
ments, which  need  not  be  large.  If  ice  is  used  in  the  refrigerator  it  may  be  in  the 
rear,  taken  in  through  a  rear  door  or  elevator  and  packed  up  against  the  shelving. 
If  the  refrigeration  is  part  of  a  brine  plant,  the  coils  may  be  at  the  rear  and  the  shelves 
left  free.  One  of  the  compartments  will  be  devoted  to  cream,  milk,  butter,  and 
cheese;  it  will  not  matter  if  the  eggs  are  also  kept  there;  another  may  be  used  for  the 
salads,  celery,  and  the  like;  a  third  may  be  used  for  the  days'  meats,  and  a  fourth 
may  be  used  for  keeping  cool  such  prepared  dishes  as  jellies  and  custards.  The 
supplies  used  in  the  diet  kitchen  will,  of  course,  be  kept  in  the  respective  refrigerators 
elsewhere,  except  from  day  to  day. 

It  goes  without  saying  that  there  must  be  a  steam  table  in  the  diet  kitchen,  and 
this  should  be  large  enough  to  contain  not  only  the  cereals  to  be  steamed  over  night, 
but  it  will  be  necessary  to  provide  steam-table  space  for  whatever  staple  meats  or 
vegetables  or  soups  are  cooked  in  the  general  kitchen  and  brought  over  for  distri- 
bution. 


238  EQUIPMENT   OF   THE    HOSPITAL 

There  must  be  at  least  one  range  in  the  diet  kitchen,  which  need  not  be  very 
large,  even  though  the  institution  itself  be  a  large  one,  because  most  of  the  roasting 
is  done  in  the  general  kitchen,  and  it  will  be  necessary  to  devote  most  of  the  cooking 
space  on  the  diet  kitchen  range  to  broiling  purposes  for  steaks,  chops,  and  birds, 
and  there  must  be  a  toaster  also. 

It  is  highly  essential  that  there  should  be  plenty  of  water,  hot  and  cold,  in  the 
kitchen,  and  the  sinks  should  all  be  supplied  with  stoppers  at  the  bottom,  so  that 
plenty  of  water  can  be  had  for  the  washing  of  spinach,  lettuce,  and  celery,  and  it 
will  be  found  convenient  to  have  movable  perforated  shelving  part  way  across  the 
sinks  to  contain  vegetables  while  cold  water  is  running  over  them ;  the  shelving  can 
be  made  out  of  white  metal  or  copper,  neither  of  which  will  corrode  easily,  or  even 
slatted  wood. 

Another  essential  of  the  diet  kitchen  is  a  large  framed  felt-covered  board  on 
one  of  the  walls,  on  which  there  are  plenty  of  labeled  hooks  to  segregate  and  classify 
the  diet  slips;  and  it  will  serve  a  most  excellent  purpose  if  this  menu  board  is  divided 
off  into  segments,  one  for  each  of  the  pupil  nurses  working  in  the  kitchen,  so  that  the 
dietitian  may  divide  the  work  among  her  assistants,  just  as  a  copy  cutter  does  the 
work  of  a  composing  room;  and  if  this  classification  and  division  and  the  handling 
of  this  board  are  done  systematically,  it  will  mean  much  in  favor  of  correct  methods 
and  reliability  in  the  preparation  and  serving  of  special  diets.  The  walls  of  the 
diet  kitchen,  where  space  will  allow,  may  be  decorated  with  charts,  showing  the 
cuts  of  meats  on  various  animals  and  their  location.  By  far  the  best  of  these  charts 
are  prepared  by  the  Pratt  Institute,  of  Brooklyn,  and  they  may  be  had  at  a  price 
that  barely  covers  the  cost  of  production. 

It  is  essential  that  there  be  a  dish  warmer  in  the  diet  kitchen  similar  to  that  we 
have  described  for  the  larger  kitchen,  and  there  should  also  be  a  large,  roomy  closet 
with  bins  for  the  keeping  of  flours  and  meal,  metal  receptacles  for  cloves  and  spices, 
and  various  condiments,  and  there  should  be  plenty  of  shelving  in  this  closet  for  the 
odds  and  ends  constantly  in  use.  In  addition  to  this  closet  there  should  also  be 
one  large  cupboard,  with  rack  space  for  pots  and  pans  and  the  ordinary  kitchen 
utensils.  Nothing  looks  so  disorderly  and  conduces  so  much  to  slovenliness  as  a 
workshop  of  any  kind  in  which  there  is  no  regular  receptacle  for  things  not  in  use. 

In  the  section  on  Architecture  the  conveniences  aimed  at  in  the  location  of  the 
dumb-waiters  is  treated  with  sufficient  amplitude,  so  that  we  need  not  dwell  on 
this  subject  at  this  place. 

THE  BUTCHER  SHOP 

The  butcher  shop  is  one  of  the  important  auxiliaries  of  the  general  kitchen,  and 
its  equipment  is  neither  a  difficult  nor  complicated  one;  but  having  it  rightly  placed 
means  a  tremendous  amount  in  the  saving  of  time  and  the  cleanliness  involved  in 
the  preparation  of  the  meats.  As  the  kitchen  diagram,  page  44,  will  show,  the 
meat  refrigerator  should  be  immediately  off  the  butcher  shop,  and  this  refrigerator 
should  be  long  and  wide  enough  to  permit  the  hanging  of  carcasses  on  both  sides, 
with  a  walkway  down  the  center.  If  the  refrigerator  is  cooled  by  coil  refrigeration, 
this  will  be  an  easy  architectural  plan ;  if  the  refrigerator  is  cooled  by  ice  carried  in, 
there  should  be  easy  access  from  the  outside  by  a  slide  or  chute,  so  that  the  ice 
may  be  easily  stored  in  the  compartments  arranged  for  it.  Even  if  the  institution 
be  a  very  small  one,  there  should  be  room  enough  in  the  refrigerator  to  hold  a  car- 
cass of  beef,  one  or  two  of  mutton,  one  of  veal,  and  perhaps  a  hog,  with  additional 
room  for  fowls  and  birds,  and  there  should  also  be  shelf-room  for  the  keeping  of 
left-over  cooked  meats.     These  may  be  just  as  well  kept  in  the  meat  house,  as  there 


EQUIPMENT   OF   THK    KITCHEN 


239 


is  no  sanitary  reason  why  they  should  not  lie,  and  it  will  save  having  a  separate 
refrigerator  for  them.  Fish,  however,  should  never  be  kept  in  the  refrigerator  in 
which  the  meat  is  hung.  The  atmosphere  of  fish  is  tainted  with  the  odor,  and  meats 
kept  in  the  vicinity,  even  at  a  very  low  temperature,  will  oftentimes  carry  a  disa- 
greeable odor,  as  well  as  taste,  so  that  there  should  be  an  independent,  isolated  refrig- 
erator or  ice-box  for  the  fish. 

Every  butcher  shop  should  contain  a  chopping-block,  and  the  made-up  ones  are 
best,  because  of  the  difficulty  of  obtaining  good  hard-wood  chopping  blocks  without 
cracks,  and  four  tables,  one  to  contain  the  beef,  mutton,  veal,  and  pork,  brought 
out  to  be  cut  up,  one  for  cleaning  and  dressing  fowls,  and  a  third  for  dressing  fish. 
There  should  likewise  be  two  sink  basins,  one  for  fowls  and  one  for  fish.  The 
butcher  shop  and  refrigerator  should  be  well  lighted,  and  both  thoroughly  drained, 
so  that  a  hose  can  be  turned  in  for  cleaning  them.  The  floor  of  the  butcher  shop 
should  be  of  concrete  or,  preferably,  some  one  of  the  granitoid  pavements,  which 
are  much  smoother  and  more  easily  kept  clean. 


Fig.  13S.— Refrigerator. 


In  connection  with  the  butcher  shop  there  should  be  a  scale,  registering  to  at 
least  10(10  pounds.  A  cheap  scale  is  not  an  economy,  but  may  cost  a  good  deal 
in  the  course  of  a  year  by  false  weighing,  and,  if  one  has  a  scale  known  to  register 
correctly,  he  may  feel  perfect  freedom  in  checking  up  the  weights  of  the  meat  deliv- 
ery to  see  that  the  institution  is  not  short-weighted.  If  the  scale  is  a  poor  one, 
likely  to  get  out  of  order,  the  butcher,  or  storekeeper,  or  receiving  clerk  will 
loose  confidence  in  its  reliability,  and  will  presently  cease  to  protest  when  his 
weights  differ  from  those  of  the  invoice  brought  to  him,  and  a  curious  thing  about 
meat  invoices  is  that  they  seem  never  to  err  advantageously  to  the  institution. 

The  butcher  shop  should  be  large  enough  to  allow  at  least  three  or  four  people 
to  work  in  it  at  one  time;  one  may  be  cleaning  fowls,  another  fish,  and  the  butcher 
himself  may  be  at  his  meats.  It  naturally  follows  that  the  ventilation  of  the 
butcher  shop  ought  to  be  good,  and  it  should  have  plenty  of  daylight,  so  that  the 
work  people  can  be  comfortable;  there  is  nothing  more  likely  to  conduce  to  shift- 


240  EQUIPMENT    OF   THE    HOSPITAL 

lessness  on  the  part  of  the  employees  of  an  institution  than  an  ill-lighted  and  ill- 
ventilated  working  place,  and  there  is  nothing  so  likely  to  conduce  to  cleanliness 
as  plenty  of  light  everywhere. 

In  the  plan  for  kitchen  suite,  the  fruit  and  vegetable  refrigerators  are  shown  to 
open  only  into  the  butcher  shop.  There  is  a  definite  purpose  in  this  arrangement: 
where  these  rooms  open  independently  into  the  kitchen  the  help  soon  get  into  the 
habit  of  stopping  as  they  pass  by  to  purloin  an  orange  or  apple,  or  even  a  tomato  or 
bunch  of  radishes,  and  the  loss  amounts  to  a  good  deal  in  the  course  of  the  year. 
The  butcher  or  any  one  person  can  be  clothed  with  the  responsibility  of  guardian- 
ship and  held  to  account,  while  the  goings  and  comings  of  many  people  spell  ir- 
responsibility and  waste. 

If  there  is  no  genera*!  system  of  refrigeration,  ice,  if  properly  placed,  does  very 
well,  as,  for  instance,  as  shown  in  Fig.  138.  Here  the  ice  is  brought  from  above  and 
through  a  special  doorway,  and  placed  at  the  roof  of  the  refrigerator. 

THE  STOREROOMS 

The  equipment  of  storerooms  for  any  institution,  large  or  small,  is  a  very  simple 
matter,  but  the  location  of  these  rooms  is  extremely  important,  considered  from 
the  standpoint  of  economy  in  time.  It  must  be  understood  that  the  storekeeper 
is  the  receiving  clerk  of  the  institution,  and  it  will  be  found  best  to  have  him  receive 
and  receipt  for  everything  brought  to  the  institution,  whether  it  be  a  paper  of  pins 
or  a  load  of  groceries  or  the  coal  supply,  so  that  the  location  of  the  storerooms  is 
an  important  matter,  if  viewed  from  the  standpoint  of  convenience  for  the  recep- 
tion of  goods,  and  the  storerooms  of  various  sorts  ought  to  be  so  arranged  that  they 
can  be  reached  from  the  vehicles  in  which  they  arrive. 

There  ought  to  be  a  centrally  located  retail  store,  the  distributing  point  for  the 
several  departments,  where  small  quantities  can  be  expeditiously  obtained.  This 
room  ought  to  be  very  convenient  to  the  kitchen  and  diet  kitchen  and  to  the 
elevator,  so  that  people  from  the  floors  who  want  goods  can  get  there  and  back 
with  the  least  possible  waste  of  time;  it  must,  of  course,  be  equipped  with  a  great 
amount  of  shelving,  and  there  ought  to  be  cupboards  which  can  be  locked  independ- 
ently of  the  store  itself,  for  the  keeping,  for  instance,  of  liquors  and  wines  and  other 
goods  likely  to  attract  the  cupidity  or  appetite  of  the  help.  These  people  must 
constantly  visit  the  storeroom,  and  if  the  custodian  is  out  for  a  moment  they  will 
help  themselves,  if  possible.  Then  there  must  be  drawers  for  nuts  and  loose  articles 
of  that  sort.  There  should  be  glass-covered  cupboards  for  the  keeping  of  surplus 
stocks  of  valuable  cloths.  There  must  be  shelving  for  small  quantities  of  glass- 
ware. There  must  be  a  great  amount  of  small  shelving  for  the  finer  canned  goods, 
like  French  peas  and  asparagus,  or  baking  powders,  spices  in  original  packages,  and 
the  like,  and  there  must  be  a  long  table  in  the  middle  of  the  room  for  the  cutting  of 
cloth  and  the  setting  of  packages  of  all  sorts  and  for  the  display  of  samples.  In 
addition  to  this  central  or  retail  grocery  store,  there  must  be  several  separate  com- 
partments, perfectly  detached  for  the  keeping  of  various  stocks,  one  for  case  goods; 
and,  if  possible,  the  china  and  glassware  can  be  kept  in  this  room.  There  must 
be  another  room,  not  necessarily  a  large  one,  for  soaps  and  scouring  powders  and 
janitor's  supplies;  these  goods  must  not  be  kept  where  there  are  food  supplies,  espe- 
cially crackers,  cereals,  breakfast  foods,  tea,  and  coffee,  because  all  of  these  things 
absorb  odors  from  the  atmosphere  easily,  and  a  few  boxes  of  bar  soap  can  soon 
communicate  a  soapy  taste  to  large  quantities  of  food  supplies.  Then  it  may  be 
necessary  to  have  a  cold  room,  which  may  or  may  not  be  connected  with  the  refrig- 


EQUIPMENT   OF   THE    KITCHEN  _' I  1 

eration  of  the  house  for  the  keeping  of  surplus  fruits.  As  a  rule,  fruits  are  aol 
bought  in  very  large  quantities  in  the  summer  time,  because  they  do  not  keep  will 
even  in  such  cold  storage  as  institutions  afford,  and  they  are  received  every  day.  so 
that  their  preservation  is  a  mat  ter  of  unimportant  consideration.  But  in  the  winter 
time  considerable  quantities  of  apples,  oranges,  lemons,  grape-fruit  and  the  like 
will  be  purchased,  and  there  ought  to  be  a  room  well  separated  from  everything 
else,  built  on  the  plan  of  an  ice-box  with  filled  walls  and  filled  door,  and  an  opening 
to  the  outside  air.  This  opening  should  be  in  the  shape  of  a  small  window,  prefer- 
ably with  double  frame,  so  that  there  will  be  an  air  space  between  the  two  panes  of 
glass.  The  temperature  of  the  room  can  then  be  very  w-ell  regulated.  If  it  is  at 
all  possible,  the  stores  should  be  kept  in  rooms  where  there  are  no  steam  pipes. 
Basement  rooms  in  a  modern  building  run  a  very  even  temperature,  winter  and 
summer,  and  if  they  are  free  from  artificial  heating  apparatus,  have  good  ventila- 
tion, and  a  fair  amount  of  light,  the  usual  institution  stores  will  keep  very  well; 
if  hot  pipes  must  run  through  them,  heavy  asbestos-pipe  covering  can  be  used,  or 
even  two  wood  coverings,  with  a  small  air  space  between  the  two  layers. 

THE  PASTRY  PANTRY 

The  pastry  pantry  should  be  a  well-lighted,  well-ventilated  room  of  good  size, 
with  plenty  of  bins  for  flour  and  meals,  plenty  of  shelves  for  fruits  and  flavors  and 
condiments,  and  there  should  be  a  large  center  work  bench,  made  preferably  6 
inches  higher  than  the  ordinary  table  of  30  inches,  because  it  will  be  found  much 
easier  to  work  upon  a  3-foot  table  than  on  a  lower  one,  and  the  pastry  makers  are 
much  more  likely  to  be  careful  in  their  methods  if  they  are  not  compelled  to  stoop 
over  into  a  back-breaking  position.  This  large  table  ought  to  have  plenty  of  cup- 
boards to  contain  molds,  rolling  pins,  and  the  ordinary  pastry-making  utensils. 
Cook  books,  special  recipes,  and  the  like  may  be  kept  on  the  shelves,  or  in  some 
special  little  shelf  closet  designed  for  that  purpose.  Usually  the  pastry  cook  will 
prize  these  recipes  very  highly,  and,  as  a  rule,  will  be  interested  in  locking  her  door 
when  she  leaves  the  pantry  if  she  has  them  about  her  work  room.  The  pastry 
pantry  should,  of  course,  have  a  sink  and  basin,  and  should  have  hot  and  cold  water. 

16 


EQUIPMENT  OF  THE  SERVING  ROOMS 

The  equipment  of  the  serving  rooms  is  a  matter  of  very  great  importance,  be- 
cause, no  matter  how  direct  are  our  means  of  transportation  from  the  kitchens  to 
the  patient,  there  must  always  be  in  large  institutions  some  half-way  station  between 
the  kitchen  operatives  and  the  nursing  department,  which  must  eventually  serve 
the  food  to  the  sick  in  wards  and  private  rooms. 

In  large  institutions  the  serving  rooms  will  be  connected  directly  with  a  dumb- 
waiter, such  a  one  perhaps  as  is  described  under  the  section  on  Architecture,  using 
electric  signalling  and  safety  devices. 

The  most  important  article  of  furniture  in  the  serving  rooms  is  the  steam 
table.  This  should  be  built,  not  only  to  retain  the  heat  in  articles  of  food  that 
arrive  at  the  floors  in  some  bulk  form  for  redistribution  by  the  nurses,  but  it  should 
be  arranged  for  keeping  the  dishes  warm.  A  refrigerator  is  necessary,  either  an 
ordinary  ice-box  or  one  that  is  brine  cooled,  such  as  we  described  in  the  section 
on  Architecture.  There  must  be  a  gas  or  electric  plate  for  heating  things  and  an 
adaptable  garbage  receptacle.  There  must  be  plenty  of  shelving  room  on  which 
the  trays  may  be  set  as  they  are  being  made  up,  and  if  there  can  be  a  large  table  in 
the  middle  of  the  floor  with  one  or  two  shelves  above,  it  will  be  a  great  convenience 
for  the  nurses.  There  must  be  cupboards  with  substantial  locks  for  locking  up 
the  silverware  and  food  receptacles  of  various  sorts. 

Of  course,  there  will  be  running  hot  and  cold  water,  and  a  large  sink  with  drain 
for  dish  drying,  and  if  the  bottom  of  the  sink  has  an  adjustable  stopper,  so  that  it 
may  be  partly  filled  with  water  during  the  dish-washing  process,  it  will  be  a  con- 
venience. This  sink  should  be  furnished  with  a  strainer  at  the  exit,  so  that  articles 
of  food  may  be  caught. 

There  is  a  good  deal  of  choice  in  the  selection  of  trays  for  the  conveyance  of 
patients'  food.  Most  hospitals  use  papier  mache  trays,  about  14  by  18  inches  in 
size.  They  are  light  and  very  durable.  Some  manufacturers  are  now  making  a 
white  enamel  tray  in  two  or  three  dimensions,  but  they  must  either  be  made  so 
heavy  for  purposes  of  rigidity  that  they  are  out  of  the  question,  or,  if  made  light 
enough  to  be  serviceable,  they  bend,  and  eventually  the  enamel  comes  off,  and 
they  are  not  very  inviting.  Nickeled  metal  trays  are  also  used,  but  these  are  rather 
expensive  and  heavy. 

There  is  made  a  plate  containing  a  hot-water  container  underneath  that  is 
fairly  serviceable,  but  it  can  be  made  to  contain  only  one  article  of  food,  and  the 
food  dries  up  quickly,  notwithstanding  a  rather  tight-fitting  lid  that  goes  with  it. 
It  is  an  expensive  plate,  and  its  use  is  limited. 

The  author  has  designed  for  use  in  the  Michael  Reese  Hospital  an  individual 
hot-water  tray,  showTn  in  Fig.  139.  The  mechanism  is  obvious.  The  tank  is  made 
to  contain  about  a  gallon  of  hot  water.  The  top  of  the  water  chamber  is  of  stamped 
metal,  with  insets  for  the  small  vegetable  dishes,  and  a  larger  center  piece  to  contain 
soup.  The  soup  bowl  is  made  of  aluminum,  as,  indeed,  the  whole  tray  can  be  made 
of  that  metal.  After  the  hot  dishes  are  set  into  their  proper  places  a  light  cover  is 
placed  on  to  prevent  the  fumes  of  the  contents  from  wetting  the  tray  itself.  The 
tray  acts  as  a  final  cover  also,  and  is  made  to  contain  the  plate,  also  a  cup  and  saucer, 

212 


EQUIPMENT   OF  THE   SERVING    ROOMS 


243 


cutlery,  sugar,  and  creamers,  and  whatever  cold  dishes,  salads,  or  desserts  may  be 
desired.     This  tray  is  heavier  than  the  ordinary  tray,  because  of  the  addition  of 


Fig.  139. — Individual  hot-water  tray. 


Fig.  140. — Individual  hot-water  tray. 


hot  water,  but  it  is  carried  down  at  the  nurse's  side,  where  weight  is  not  quite  so 
great  a  consideration. 


Fig.  141. — Food  containers. 

Sometimes  a  patient  is  not  ready  for  the  meal,  and  it  will  have  to  wait  for  a 
considerable  period  of  time,  and  in  the  ordinary  trays  will  be  cold  and  uninviting. 


244  EQUIPMENT   OF   THE    HOSPITAL 

This  tray  will  keep  the  meal  hot  for  as  long  as  an  hour,  and  the  warm  vapors  are 
confined,  so  that  the  food  does  not  dry  out  rapidly. 

Food  Containers. — The  subject  of  containers  for  the  bulk  foods,  to  be  distrib- 
uted to  various  parts  of  the  house,  has  been  left  until  we  had  finished  the  descrip- 
tion of  the  general  and  diet  kitchens,  because  these  food  containers  must  go  from 
both  places  under  certain  conditions,  which  will  be  more  fully  described  under  the 
head  of  "Kitchen  Management"  in  the  section  on  Operation.  Figure  141  shows  a 
general  form  of  food  container  that  meets  most  requirements.  These  containers 
are  made  up,  as  the  illustration  shows,  of  a  large  pan  12  inches  wide,  16  inches 
long,  and  6  or  7  inches  deep,  with  tight-fitting  lid.  This  pan  must  be  strong  and, 
preferably,  reinforced  with  metal  bands.  Inside  of  these  containers  are  the  food 
pans  themselves.    One  of  these  may  be  large  enough  to  fit  very  loosely  into  one-half 


Fig.  142. — Food  car. 

the  entire  container;  another  may  fit  one-quarter  of  the  whole,  and  there  may  be 
two  others  to  occupy  the  other  quarter.  If  desired,  the  container  may  be  made 
large  enough  so  that,  instead  of  holding  four  food  pans,  it  will  hold  six  or  even 
eight,  and  when  wanted  for  use  all  of  the  food  pans  may  be  of  the  smaller  size, 
or  all  of  the  pans  may  be  of  the  largest  size;  in  other  words,  interchangeable. 

The  inside  pans  should  all  be  larger  at  the  top  than  at  the  bottom,  and  should 
be  just  large  enough  to  fit  very  loosely  into  the  container,  so  that  when  the  food 
pans  are  in  place  a  considerable  quantity  of  hot  water  may  be  poured  in.  Then 
the  lid  can  be  put  on,  and  the  food  is  ready  to  be  taken  to  the  floors,  where  it  is  set 
on  the  steam  tables  in  the  serving  rooms  about  the  house,  and  can  be  kept  hot  for 
any  reasonable  length  of  time  without  fear  that  it  will  either  dry  up  or  be  soaked 
with  water.  The  metal  out  of  which  these  food  boxes  are  made  is  a  matter  of  a 
good  deal  of  importance.     They  do  not  last  very  well  at  best,  and  if  they  are  made 


EQIII'MENT    OF   THE    SERVING    ROOMS 


245 


out  of  the  ordinary  shoot  metal  they  rust  rapidly,  and  the  expense  and  time  in- 
volved in  the  mending  of  them  counts  up  rapidly,  so  that  they  should  be  well  made 
at  first  and  of  a  metal  that  does  not  rust;  copper  is  preferable,  and,  if  the  item  of 
expense  involved  in  polishing  the  copper  vessels  is  to  be  considered,  the  copper  may 
be  tinned.  After  a  while  this  tin  coating  will  wear  off,  but  it  may  be  replaced  easily 
and  cheaply.  It  is  useless  to  make  these  containers  out  of  so-called  tin,  which  is 
only  a  sheet  of  steel  dipped  in  tin,  a  coating  so  thin  that  it  lasts  almost  no  time. 

The  Food  Cars. — In  institutions  of  large  size,  where  food  must  be  distributed 
over  considerable  areas  to  different  parts  of  the  building,  it  is  necessary  either  to 
have  several  dumb-waiters  starting  from  different  parts  of  the  basement  and  run- 


Fig.  143. — Food  car. 

ning  to  different  parts  of  the  upper  house,  or,  if  there  is  only  one  dumb-waiter, 
to  have  food  cars  for  each  floor  to  wheel  the  food  from  the  dumb-waiter  to 
the  several  parts  of  the  floor  intended  to  lie  served:  a  number  of  dumb-waiters 
located  in  different  points,  in  which  most  of  the  transportation  of  the  food  can  be 
accomplished  in  the  basement  by  a  corps  of  help  devoted  to  that  service,  under  a 
concerted  supervision,  is  best  where  the  architecture  will  permit.  In  either  case 
it  will  be  necessary  to  employ  food  ears  of  some  sort. 

Some  of  these  offered  for  sale  are  noisy  and  rumble  unnecessarily;  some  of  I  hem 
are  so  light  that  they  wear  out  or  break  easily  under  the  rough  usage  that  they  are 
bound  to  have;  again,  some  of  them  are  so  heavy  that  when  loaded  they  are  difficult 
to  handle;  there  are  others  that  do  not  lend  themselves  to  short  turns,  because  the 


246  EQUIPMENT    OF   THE    HOSPITAL 

wheels  are  too  high  to  work  under  the  body;  there  are  others,  apparently  all  right, 
that  are  made  with  flat  wheels  covered  with  tightly  drawn  belting,  or  in  some  cases 
covered  with  a  woven  cloth  containing  some  rubber  ingredient  that  makes  them 
run  smoothly  and  noiselessly,  but  this  covering  soon  stretches  and  falls  off  and  is 
difficult  to  replace  satisfactorily,  as  the  manufacturers  rarely  keep  the  material 
in  stock.  There  are  cars  whose  wheel  has  a  grooved  felloe,  like  automobile  or 
bicycle  wheels;  this  is  the  car  to  use,  and,  as  all  four  wheels  are  the  same  size,  about 
12  inches,  and  can  be  replaced  if  they  break  or  wear  out,  and  the  bicycle  tires  can 
always  be  renewed.  The  wheels  are  set  up  on  a  gearing,  the  axle  of  the  hind  wheels 
fixed  and  the  front  wheels  set  truck  fashion,  so  that  they  work  each  independent 
of  the  other  under  the  car  and  on  ball  bearings. 

The  architecture  of  the  car  is  a  matter  of  individual  choice.  If  the  framework, 
shelving,  and  supports  are  of  wood,  the  paint  wears  off,  and  the  car  presents  an 
uncomely  appearance;  if  the  structure  is  metal,  enameled  or  painted,  the  paint  or 
enamel  wears  off,  but  the  metal  car  can  at  least  be  kept  clean.  Figure  142  shows 
a  car  that  will  meet  most  requirements.  It  gives  no  trouble,  is  noiseless,  and, 
while  light,  is  very  strong,  owing  to  the  I-beams  used  for  reinforcement. 

Another  form  of  car  (Fig.  143)  contains  doors,  so  that  the  car  can  be  closed  up 
for  transportation  of  food  out  of  doors  or  over  long  distances.  The  wheel  arrange- 
ment is  the  same  in  the  two  cars.  One  has  grate  shelves  and  the  other  solid  sheet 
metal.  This  is  made  by  the  Scanlan  Morris  Co.,  of  Madison,  Wis.  There  are  other 
cars  that  are  heated,  some  by  electricity  from  an  ordinary  lamp  socket  applied  to  a 
plate  in  the  bottom,  and  others  contain  reservoirs  of  hot  water.  Individual  condi- 
tions must  guide  the  choice. 


EQUIPMENT  OF  THE  SMALL  PRIVATE  HOSPITAL 

There  are  many  very  excellent  physicians,  surgeons,  general  practitioners, 
and  specialists  who  live  in  communities  too  small  or  too  scattered  to  afford  a 
good  general  hospital,  and  a  great  many  of  these  men  are  finding  their  environ- 
ment unsatisfactory  and  their  facilities  to  do  modern  work  insufficient.  They 
are  banding  themselves  together,  therefore,  in  many  places  and  are  equipping 
large  private  homes  or  modest  houses  of  one  sort  and  another  to  do  at  least  the 
commoner  things  in  medicine,  surgery,  and  the  specialties. 

The  question  comes  up,  therefore,  What  are  the  necessities  for  such  an  equip- 
ment— not  what  would  be  desirable,  but  what  must  be  put  in  with  which  to  just 
barely  get  along?  This  question  is  placed  before  hospital  administrators  almost 
daily,  and,  with  an  apology  for  a  recommendation  of  anything  less  than  proper 
modern  equipment,  we  shall  undertake  to  answer  that  question. 

The  first  necessity,  indeed,  the  only  actual  necessity,  is  an  efficient  sterilizing 
plant.  This  can  be  made  up  very  compactly  and  set  upon  a  rack  made  of  gas- 
piping,  white  enameled.  It  can  contain  a  hot-  and  cold-water  sterilizer  of  8 
or  10  gallons  capacity  each,  a  utensil  sterilizer  about  16  inches  square,  and  one 
or  two  instrument  sterilizers  9  x  16  x  6  inches.  They  are  made  now  so  that 
an  electric  current  can  be  used  where  such  a  convenience  is  available,  and  they 
are  also  made  with  a  self-contained  generator  or  small  steam  boiler.  Any  of  the 
sterilizer  houses  will  furnish  such  a  plant  for  approximately  S300. 

A  few  rubber  sheets,  a  Kelly  pad,  or  similar  device,  for  dressing  patients  in 
bed;  a  few  hot-water  bottles,  urinals,  bed-pans,  enema  sets,  made  up  of  can, 
tube,  and  point;  a  nutritive  set  or  tube,  made  up  of  can,  tube,  points,  and  funnel; 
a  few  sputum  cups;  a  few  drinking  funnels,  basins,  pus-basins,  and  anesthetizing 
set;  either  ether  masts  or  oxygen  gas  outfit — these  are  practically  all  the  require- 
ments of  a  private  small  hospital.  Plain  three-quarter  width  white-enameled 
beds,  curled  hair  mattresses,  one  hair  pillow  and  two  feather  pillows  for  each 
bed,  one  or  two  pairs  of  blankets,  two  spreads,  and  half  a  dozen  sheets  and 
pillow  slips  will  equip  the  beds;  ordinary  trays  will  do  for  serving  meals  to 
patients  unless  the  money  is  available  for  bedside  tables;  an  ordinary  small 
table,  a  dresser,  and  a  rocker  compose  the  furniture  for  private  rooms.  There 
should  be  a  commode  or  two  in  the  house,  and  a  wheel  chair  or  two,  if  possible. 

The  surgical  appliances  need  not  be  listed.  They  will  be  made  up  to  suit  the 
inclination  of  the  individual  surgeons  who  operate.  In  the  section  on  Equip- 
ment of  the  Operating  Suite  there  will  be  found  a  very  detailed  description  of 
the  material  for  any  operating-room,  large  or  small,  and  the  manner  of  its 
preparation. 

Articles  for  the  comfort  of  private  patients  may  be  bought  or  improvised, 
such  as  back-  and  head-rests,  Morris  chairs,  and  the  like. 

Carpets  nailed  to  the  floor  should  be  tabooed;  if  the  floors  are  bad,  they 
should  be  covered  with  linoleum  and  small  rugs  used  here  and  there,  and  these 
latter  should  be  made  up  of  home-made  stuff,  or  so-called  "rag  rugs,"  that  can 
be  boiled  and  cleaned;  they  are  very  cheap. 

•247 


PART   III 
OPERATION  OF  THE  HOSPITAL 


THE  BOARD  OF  DIRECTORS 

If  we  are  to  contemplate  intelligently  the  personnel  of  the  board  of  directors 
of  a  public  or  semipublic  institution,  and  to  frame  an  opinion  as  to  the  qualities, 
social  and  business,  that  should  be  looked  for  in  a  member  of  the  board,  we  must 
first  understand  something  of  the  duties  of  the  board. 

The  board  of  directors  is  the  hub  around  which  must  revolve  all  the  activities 
of  the  institution.  It  is  not  only  the  creative,  constructive  body,  but  it  is  the 
operative  body  and  the  executive  inspiration  of  the  institution.  Its  members  must 
be  not  only  alert,  active,  intelligent  members  of  the  community,  but  they  should  be 
people  who  cover  a  large  field  socially,  intellectually,  and  financially. 

One  of  the  duties  of  the  board  is  to  buy  land  and  construct  a  building,  and  there 
should  be  a  few  members  who  are  familiar  with  real  estate  and  building  enter- 
prises, and  the  other  members  of  the  board  ought  to  be  well  enough  balanced 
individuals  to  recognize  their  inability  to  cope  with  these  particular  problems  and  to 
allow  of  their  handling  by  those  who  are  most  competent.  Another  duty  of  the 
board  is  to  appoint  executive  officers,  and  there  should  be  at  least  two  or  three 
members  who  are  accustomed  to  handle  people,  and  to  judge  of  their  value  and  to 
get  work  out  of  them.  Another  duty  of  the  board  is  to  finance  the  institution, 
and  there  should  be  two  or  three  members  whose  business  is  finance,  and  who  know 
figures,  and  who  can  appreciate  balances  and  make  comparisons  of  value  in  figures, 
whether  it  be  goods  purchased  or  work  clone.  Another  duty  of  the  board  is  to 
secure  money  with  which  to  operate  the  institution,  and  every  board  of  directors 
should  contain  in  its  membership  several  people  who  have  the  utmost  confidence 
of  the  community,  and  who  can  go  to  individuals  and  command  not  only  respect, 
but  material  support.  Another,  and  perhaps  the  most  important  duty  of  a  board 
of  directors,  is  to  give  personal  attention  to  the  conduct  of  the  institution  for  which 
it  is  to  be  held  responsible.  The  crying  need  in  directorates  of  institutions  in  this 
country,  operated  without  profit,  is  for  men  and  women  who  will  take  a  personal 
interest.  This  does  not  mean  that  a  board  of  directors  should  divide  itself  up  into 
committees  to  look  after  the  janitors  and  housework,  or  to  run  the  training-school, 
or  to  tell  the  members  of  the  medical  staff  how  to  treat  their  patients;  too  many 
boards  of  directors  contain  just  such  members,  members  who  have  plenty  of  time 
on  their  hands,  but  very  little  else  to  give  to  the  institution ;  who  have  little  influ- 
ence in  the  community,  who  have  less  judgment,  and  who  eventually  earn  the  whole- 
some contempt  of  those  who  have  to  do  the  real  work  in  the  institution — that  is,  the 
salaried  employees. 

The  question  of  whether  a  board  of  directors  should  be  made  up  partly  of  men  and 
partly  of  women  will  depend  very  much  upon  individual  conditions:  first,  the 

248 


THE    BOARD    OF   DIRECTORS  249 

character  of  the  institution;  second,  the  available  material  out  of  which  to  choose 
the  directors.  There  is  no  question  that  every  institution,  now  operated  exclusively 
by  men,  would  lie  better  administered  if  it  had  the  leavening  influence  of  one  or 
more  of  the  right  sort  of  women ;  the  great  trouble  is  and  has  been  to  get  the  right 
sort  of  women.  More  times  than  not,  when  a  women  is  chosen  for  membership 
on  a  board  of  directors,  it  is  because  she  or  her  family  has  given  some  money  for 
the  construction  or  support  of  the  institution,  and  too  many  times  such  a  woman 
will  feel  under  an  obligation  to  spend  her  time  watching  the  expenditure  of  the 
money  she  is  supposed  to  represent.  Such  an  influence  will  not  make  for  very 
much  good  in  an  institution.  On  the  contrary,  it  will  be  hurtful  in  the  extreme. 
Another  woman  perhaps  may  be  chosen  for  her  individual  activity,  her  industry 
in  securing  gifts  for  the  institution — perhaps  of  linen  or  articles  of  clothing — and 
such  a  woman  will  too  often  insist  upon  managing  the  whole  linen  department,  and 
upon  giving  orders  to  everybody  concerned  in  the  distribution  and  use  of  the 
articles  which  she  has  had  a  hand  in  collecting,  and  such  an  influence  is  not  a 
wholesome  one  in  any  institution. 

In  other  words,  the  best  conducted  institution  of  whatever  kind  will  be  that  in 
which  the  members  of  the  board  of  directors  are  large  and  broad  men  or  women,  or 
both,  who  will  insist  upon  the  selection  of  the  right  sort  of  executives;  who  will,  in 
a  practical  way,  watch  the  conduct  of  the  institution,  to  see  that  its  paid  officers 
make  the  most  of  their  opportunities  and  facilities;  who  will  be  potent  in  securing 
material  resources,  and  who  will  guard  its  efficiency  and  modernity;  and  yet,  a 
board  of  directors  that  can  and  will  encourage  all  of  its  officers  to  do  their  utmost 
for  the  common  good,  that  will  encourage  all  the  factors  in  the  institution  to  work 
in  harmony,  and  with  a  common  helpfulness. 

Board  members  of  these  institutions  are  usually  prominent  members  of  society; 
they  have  many  friends  who  are  likewise  friends  of  the  institution;  they  have 
constant  opportunity  to  test  the  esteem  in  which  the  institution  is  held;  to  hear 
complaints  of  service,  of  policy,  and  even  of  the  medical  care  patients  are  receiving. 
There  is  no  more  serious  duty  of  board  membership  than  to  give  the  institution 
the  benefit  of  such  complaints,  and  of  the  oftentimes  valuable  advice  accompany- 
ing them.  The  superintendent,  if  he  be  worthy  of  the  position  he  holds,  should 
welcome  and  profit  by  such  vigilant  interest  on  the  part  of  his  board  members, 
and  take  advantage  of  every  complaint  and  of  every  item  of  advice — not  always  to 
follow  it  perhaps,  but  to  weigh  it  and  give  it  consideration.  The  superintendent 
has  no  such  close  touch  with  the  outside  world  as  have  his  board  members,  and 
very  often  interested  people  refrain  from  confiding  to  him  what  is  on  their  minds, 
sometimes  because  they  think  he  is  responsible  for  the  thing  complained  of,  and 
sometimes  because  they  arc  not  on  sufficiently  confidential  terms  with  him;  in 
any  event,  he  has  a  right  to  all  the  information  his  board  members  can  supply, 
to  the  end  that  he  may  better  conditions  and  give  a  higher  order  of  administra- 
tion. 

How  Created. — The  manner  of  the  creation  of  a  board  of  directors  will  depend 
largely  upon  conditions  in  individual  cases.  Naturally,  the  board  of  directors  will 
be  chosen  to  represent  the  people  who  support  the  institution  by  their  philan- 
thropy and  charity,  and  that  will,  at  the  same  time,  be  representative  of  the  bene- 
ficiaries of  the  institution.  As  a  rule,  the  institution  will  be  chartered  under  the 
law  of  some  state  as  a  "no  profit"  enterprise.  Its  charter  will  give  it  certain  privi- 
leges extended  to  those  who  put  up  the  money  for  its  support,  the  privilege  of  elect- 
ing a  board  of  directors,  and  of  saying  in  its  constitution  how  the  successors  to  these 
members  shall  be  chosen.     Generally  speaking,  boards  of  directors  arc  chosen  for 


250  OPERATION    OF   THE    HOSPITAL 

varying  periods.  At  the  creation  of  the  enterprise,  for  instance,  a  number  of 
directors  will  be  chosen  for  one  year,  a  similar  number  for  two  years,  and  others 
for  three  or  perhaps  four  years,  so  that  after  the  first  year  a  certain  number  of 
members  will  fall  out,  or  be  obliged  to  stand  for  re-election  at  the  hands  of  the  mem- 
bers or  stockholders,  so  to  speak,  of  the  corporation. 

In  some  institutions  the  whole  board  is  chosen  annually,  a  practice  that  has  the 
disadvantages  of  changing  policies  and  practices  following  every  annual  meeting. 
There  is  no  consistency  or  constancy  in  the  operation  of  such  an  institution.  No 
one  can  take  the  same  serious  interest  in  its  welfare  as  where  the  institution  is  com- 
posed of  a  board  whose  policies  are  definitely  fixed,  and  whose  members  have  definite 
ideals  of  a  fixed  destiny,  and  whose  membership  changes  so  little  from  year  to  year 
that  these  policies  cannot  be  changed  following  any  single  annual  election. 

Oftentimes  the  people  on  the  outside  are  not  well  informed  about  the  affairs 
of  an  institution,  and  they  will  sometimes  set  up  for  election  some  member  of  the 
community  wholly  opposed  to  the  policies  of  the  board  of  directors,  and  whose 
campaign  for  election  perhaps  is  a  cry  for  investigation  and  upheaval  and  reversal. 
It  has  been  known  that  such  a  member  after  election,  and  after  proper  study  of 
the  institution's  policies,  welfare,  and  needs,  has  changed  about  utterly,  and  has 
become  one  of  the  staunchest  supporters  of  the  policies  of  the  board.  This  fact 
means  two  things :  first,  that  the  public  should  be  always  taken  into  the  confidence 
of  the  board  of  directors  of  a  semipublic  institution;  it  should  be  kept  well  advised 
of  everything  that  goes  on  there ;  second,  it  means  that  every  institution  interested 
in  the  welfare  of  the  community  at  large,  without  hope  of  profit  to  any  individual, 
should  not  only  have  settled  policies  and  definite  ideals,  but  the  board  should  be 
so  constructed  that  these  ideals  and  policies  cannot  be  subverted  or  changed  over 
night  in  obedience  to  a  popular  and  perhaps  unjust  cry. 

Authority. — The  authority  of  the  board  of  directors  should — indeed,  must — be 
absolute,  and  naturally  the  board  will  be  always  answerable  to  those  who  elect  it. 

But  the  authority  of  the  board  of  directors  cannot  be  wisely  exercised  through 
individual  members  on  their  individual  initiative;  in  other  words,  the  authority 
of  the  board  cannot  be  delegated  to  committees  or  sub-committees.  These  are 
not  intended,  and  should  not  be  used  for  any  such  purpose.  The  president  of  the 
board  of  directors  should  not  only  be  the  spokesman  in  matters  expressing  the 
board's  wishes,  but  he  should  be  the  authority  of  the  institution,  except  when  the 
board  is  in  session,  and  the  president,  therefore,  must  be  answerable  to  the  board 
at  all  times  for  his  actions  and  subject  to  the  board's  commands.  The  only  officers 
of  a  board  of  directors  of  a  public  institution  who  should  have  an  executive  voice 
are  the  president,  and  in  his  absence  the  vice-president,  and  the  treasurer — the  one 
to  represent  the  board  when  it  is  not  in  session,  and  to  give  orders  concerning  the 
material  welfare  of  the  institution  itself,  and  the  other  to  guide  and  guard  the 
institution's  finances. 

Committees. — The  board  of  directors  should  be  divided  into  a  number  of  com- 
mittees in  order  to  facilitate  the  work  that  the  board  has  to  do,  and  these  commit- 
tees should  be  chosen  carefully,  with  special  reference  to  the  qualifications  of  the 
members  for  the  work  the  committee  has  to  do.  Generally  speaking,  committees 
will  work  through  the  superintendent  of  the  institution;  at  least,  they  should  do  so, 
and  it  should  be  their  duty  to  help  him,  with  their  wisdom  and  judgment,  to  a  solu- 
tion of  the  many  problems  that  must  confront  him,  as  it  should  be  his  duty  and  his 
pleasure  to  avail  himself  of  their  aid  and  support  and  experience  at  every  turn. 
But  the  jurisdiction  of  committees  should  not  become  executive;  in  other  words, 
they  should  have  no  power  to  direct  or  command  the-superintendent  or  any  other 


THE    BOARD    OF    DIRECTORS  251 

officer  of  the  institution,  and  their  functions  should  cease  with  the  power  of  recom- 
mendation, or,  at  most,  their  duty  will  end  by  calling  the  matter  at  hand  to  the 
attention  of  the  president,  and  by  reporting  it  to  the  whole  board  at  its  next  meet- 
ing. 

If  it  came  to  pass  in  any  institution  that  the  committees,  or  the  chairman  of  a 
committee,  or  an  individual  member  of  a  board,  had  the  power  to  give  orders  to 
the  superintendent  or  to  the  officials  of  the  institution,  the  work  of  the  institu- 
tion would  at  once  enter  upon  a  chaotic  regime,  without  head,  without  guidance 
or  control,  and  such  a  superintendent  would  become  at  once  the  play  of  contending 
currents,  ineffective  and  vacillating,  for  fear  of  offending  some  dominant  factor  in 
the  board,  and,  finally,  he  would  be  a  conspicuous  failure,  with  perhaps  inherent 
ability  to  become  a  distinct  success  under  other  conditions. 

Meetings  of  the  Board. — A  board  of  directors  has  no  right  to  dispense  with  its 
regular  meetings,  and  one  of  the  chief  factors  in  bringing  about  dry  rot  and  stag- 
nation in  an  institution  is  the  failure  on  the  part  of  the  board  of  directors  to  meet 
regularly,  to  meet  frequently,  and  to  have  its  full  membership  present  at  its  meet- 
ings ;  one  of  the  most  vital  forces  in  a  virile,  business-like,  pushing  administration  is 
an  active  board  of  directors. 

Nothing  tends  so  much  to  make  one  lackadaisical,  and  to  cause  one  to  lose  inter- 
est in  an  enterprise,  as  absence  from  the  meetings  at  which  its  affairs  are  discussed. 
Nothing  tends  so  much  to  an  active  interest  on  the  part  of  the  salaried  people  of 
an  institution  as  an  active  and  personal  interest  on  the  part  of  the  directors. 
Meetings  can  be  held  too  often,  because  the  most  desirable  members  for  a  board  of 
directors  are  usually  busy  people,  who  find  it  impossible  to  attend  very  frequently, 
so  that  meetings  should  not  be  held  so  close  together  that  the  members  cannot  find 
time  to  attend,  and  times  of  meeting  ought  to  be  so  chosen  that  the  members  can 
attend.  In  a  good  many  institutions  it  has  been  found  that  Sunday  morning,  or  at 
least  some  hour  on  Sunday,  is  the  best  possible  time  for  the  meetings  of  the  board 
of  directors  of  such  institutions  as  we  are  now  discussing.  If  the  sacredness  of 
the  Sabbath  be  offered  as  a  reason  why  these  meetings  should  not  be  held  on  that 
day,  it  might  be  asked,  is  there  any  higher  or  holier  duty  than  participation  in  the 
successful  management  of  an  institution  devoted  to  the  welfare — physical,  mental, 
or  moral — of  the  people  of  the  community,  and  especially  the  dependent  members? 

Womens'  Auxiliary  Boards. — In  some  very  wisely  conducted  hospitals,  whether 
the  board  of  directors  is  made  up  entirely  of  men  or  is  a  mixed  board  of  men  and 
women,  they  have  added  to  the  governing  authority  certain  auxiliary  boards  of 
women,  contributors  to  the  funds,  wives  of  trustees,  or  members  of  the  medical 
stall',  or  members  of  the  religious  body  under  whose  auspices  the  hospital  is  con- 
ducted, and  these  boards  operate  in  a  measure  as  committees,  and  have  at  least 
theoretic  charge  of  certain  physical  parts  of  the  hospital  management.  There  is 
a  committee,  for  instance,  in  charge  of  the  linens  and  laundry  work,  a  committee 
in  charge  of  hospital  furnishings,  a  committee  to  collaborate  with  the  nursing 
enterprises  of  the  hospital,  another  visiting  committee,  and  so  on  along  the  whole 
line  of  physical  activities  of  the  hospital. 

As  a  rule,  these  womens'  committees  have  not  the  direct  charge  of  their  several 
departments.  They  cannot,  of  course,  give  definite  orders,  and  their  function  is 
more  or  less  of  an  advisory  character. 

These  womens'  boards  are  most  excellent  adjuncts  to  the  active  management 
of  any  institution.  As  a  rule,  their  members  are  entirely  reasonable,  ami  they 
recognize  that  there  cannot  be  several  directing  bodies,  and  that  their  office  must 
be  an  advisory  one.     And  if  these  womens'  auxiliaries  are  conducted  tactfully, 


252  OPERATION    OF   THE    HOSPITAL 

both  on  behalf  of  their  own  officers  and  members  and  in  behalf  of  the  hospital 
active  administration,  only  good  can  come  out  of  their  activities. 

In  the  first  place,  these  women  are  made  thoroughly  informed  of  the  hospital's 
possibilities  and  limitations,  and  they  are  very  likely  to  become  so  enthusiastic 
over  their  work  that  they  will  go  out  among  the  public  at  any  time  and  secure 
contributions  of  either  money  or  material,  and  in  a  good  many  hospitals  they  make 
up  no  inconsiderable  part  of  the  hospital  furnishings,  linens,  and  the  like,  by  their 
own  unaided  activities  in  the  way  of  collections. 

Perhaps  the  best  function  of  all,  and  the  most  valuable  one  from  the  standpoint 
of  the  hospital,  is  that  the  members  of  these  womens'  auxiliary  boards  are  out  on 
the  firing-line,  so  to  speak,  to  keep  peace  between  the  hospital  and  the  public.  There 
was  never  a  hospital  created  about  whose  management  there  was  not  fault  finding 
from  some  section  of  the  community.  Sometimes  such  complaints  are  unjustified, 
even  where  the  things  complained  of  are  true.  For  instance,  there  may  be  a  com- 
plaint about  torn  or  stained  linen,  and  these  women  will  know  definitely,  and  can 
explain  to  the  public  that  while  the  linens  may  be  torn  and  stained  yet  this  is  due 
entirely  to  the  financial  limitations  of  the  institution,  that  will  not  permit  them  to 
indulge  in  better  grades  of  linen  or  new  linen  when  it  is  needed.  Perhaps  there  is 
trouble  with  the  food,  and  the  public  is  talking  about  it.  Now  we  all  know  that 
patients  and  patients'  friends  are  very  apt  to  find  fault  with  the  food  in  a  hospital. 
The  patients  find  fault  with  it  because  they  are  sick,  and  have  no  appetite  in  any 
event,  and  perhaps  they  are  on  a  diet,  by  the  doctor's .  orders,  that  is  repulsive  to 
them,  and  this  is  charged  up  to  the  institution  itself  and  its  management;  then  we 
know  that  in  an  institution  it  is  impossible  to  provide  food  and  to  serve  it  exactly 
as  we  have  it  in  our  own  homes,  and  there  is  a  complaint  on  that  account  from  the 
nurses  and  interns  and  executive  officers.  There  is  also,  to  be  sure,  a  certain  same- 
ness and  monotony  in  the  food  service  of  a  large  institution,  and  all  these  things  go 
to  the  public  in  the  form  of  complaints,  and  there  is  no  influence  in  the  community 
half  so  strong  to  stem  the  tide  of  fault  finding  with  an  institution  like  a  good,  strong 
auxiliary  board  of  women  that  know  the  facts,  whether  they  are  justified  or  not. 
If  they  are  justified,  these  women  are  quite  capable  of  making  all  sorts  of  a  row  to 
change  the  conditions,  and  if  the  complaints  are  not  justified,  leave  it  to  them  to 
see  that  the  actual  facts  are  placed  before  the  public  in  a  proper  manner,  to  the 
relief  of  the  institution. 

It  has  been  claimed  sometimes  that  these  auxiliary  boards  of  women  are  meddle- 
some and  officious,  and  that  they  are  likely  to  keep  things  in  a  ferment  and  turmoil 
in  the  institution.  Of  course  this  may  be  true  in  individual  cases,  and  probably 
sometimes  will  be  so,  but  an  exception  to  the  rule  is  not  a  sufficient  condemnation 
of  a  practice,  and  it  is  certainly  true  that  these  boards  of  women  are  perhaps  the 
greatest  of  all  factors  in  the  success  of  the  institution,  and  if  here  and  there,  in  an 
individual  case,  the  women  are  meddlesome,  it  seems  to  many  of  us  who  have  had 
a  broad  experience  in  this  field  that  a  leavening  process  is  achieved  by  the  sanity 
and  reason  and  common  sense  of  a  majority  of  the  members.  Personally,  the  author 
has  found  some  of  his  greatest  inspirations  in  the  advice  and  counsel  of  the  level- 
headed women  members  of  the  committee  devoted  to  the  institution. 


THE  SUPERINTENDENT  OF  THE  HOSPITAL 

The  superintendent  of  the  hospital  is  the  executive  officer  of  the  board  of 
directors — the  general  manager  of  the  corporation.  Standards  of  hospital  admin- 
istration have  been  practically  revolutionized  within  the  past  five  or  ten  years, 
and  the  standards  of  hospital  managers  have  changed  within  the  same  time.  The 
man  or  woman  who  was  a  competent  hospital  director  a  few  years  ago  may  be  to- 
day so  far  behind  the  times  that  the  whole  institution  is  out  of  date. 

In  the  old  days,  if  the  hospital  manager  was  economical  in  his  purchase  and 
distribution  of  supplies,  if  he  kept  his  house  clean,  kept  the  bugs  out  of  the  beds, 
and  gave  his  patients  fairly  decent  food  to  eat,  he  was  considered  an  exemplary 
and  illuminating  example  of  a  hospital  superintendent.  To-day  the  whole  aspect 
is  changed.  He  must  not  only  do  these  things  or  know  how  to  direct  them,  but 
he  is  expected  to  keep  abreast  of  medical  and  surgical  progress,  to  know  what 
new  apparatus  of  a  medical  or  surgical  kind  should  be  bought  and  used.  He 
must  know  the  laws  of  asepsis,  and  at  least  enough  about  the  character  of  the  com- 
municable diseases  to  guard  not  only  against  their  appearance  in  the  institution, 
but  to  prevent  their  spread,  by  proper  isolation  and  disinfection;  and,  as  these 
offices  are  performed  under  definite  and  rigid  rules  and  scientific  conditions,  he 
must  be  in  touch  with  medical  science  in  order  to  perform  them.  If  he  does  not 
know  the  laws  of  hydrotherapy  and  the  various  forms  of  physical  therapy  he  must, 
at  least,  know  sufficient  about  them  to  select  competent  workers  in  those  depart- 
ments and  to  judge  of  their  qualifications.  If  he  is  not  a  trained  dietitian,  he  must 
at  least  be  sufficiently  well  informed  on  the  physiology  of  digestion,  the  chemic 
constituents  of  food,  and  the  functions  of  the  digestive  organs  of  the  body  to  direct 
a  proper  dietary,  not  only  in  the  main  kitchen,  but  in  the  special  diet  department. 
If  the  modern  superintendent  is  not  an  expert  in  the  purchase,  testing,  analysis, 
and  formulations  of  infant  foods  in  the  milk  laboratory,  he  must  at  least  be  suffi- 
ciently well  informed  to  see  that  this  work  is  done  properly  and  under  scientific 
conditions  and  to  appreciate  its  value. 

If  the  modern  superintendent  is  not  a  surgeon  or  internist,  or  pediatrician  or 
gynecologist  or  obstetrician,  he  must  at  least  be  sufficiently  well  informed  on  all 
of  these  subjects  to  engage  in  intelligent  conference  with  the  members  of  his  medi- 
cal staff,  to  help  them  create  rules  for  the  operation  of  their  departments,  to  equip 
them  with  proper  apparatus  for  their  work,  and  to  intelligently  purchase  for  them 
proper  current  supplies. 

How  long  would  the  business  manager  of  a  mercantile  corporation  be  per- 
mitted to  occupy  his  position  who  did  not  know  how  the  details  of  the  business 
were  performed,  who  was  not  fully  conversant  with  the  processes  of  manufacture 
of  the  article  in  which  his  corporation  dealt,  who  did  not  know  the  intricacies  of 
the  business  from  both  its  buying  and  selling  side?  In  these  business  corporations 
the  proprietors  or  owners  or  officers  give  personal  attention  to  the  business,  and  are 
generally  active  in  the  direction  of  their  affairs;  how  much  more  important  is  it, 
therefore,  that  the  superintendent  of  the  hospital,  who  must  be  the  highest  active 
officer,  should  be  one  who  knows  every  detail  of  the  institution's  activities?  The 
chief  business  of  the  hospital  is  the  care  and  cure  of  the  sick,  and  every  other 

253 


254  OPERATION    OF   THE    HOSPITAL 

function  merely  involves  a  detail  of  this  work.  And  yet  there  are  those  who  hold 
that  the  best  hospital  administrator  is  he  who  can  buy  supplies  best,  or  he  who 
can  keep  the  cleanest  house,  or  he  who  can  keep  the  accounts  of  the  institution 
best. 

In  view  of  these  thoughts,  it  must  be  self-evident  that  the  hospital  administrator 
must  be  a  many-sided,  intelligent,  versatile  man  or  woman.  He  or  she  must  know 
a  great  many  things  on  a  great  many  subjects.  It  goes  without  saying,  however, 
that  the  hospital  superintendent  will  hardly  ever  be  a  specialist,  except  in  his  own 
work;  indeed,  the  very  fact  of  specializing  would  be  a  prominent  factor  in  his  un- 
doing as  a  competent  hospital  administrator. 

There  are  many  hospitals  in  which  the  superintendent  is  a  member  of  the 
medical  staff  and  does  part  of  the  professional  work.  Especially  is  this  true  of 
special  hospitals,  such  as  railroad  institutions  and  maternity  hospitals,  and  it  is 
equally  true  of  some  of  the  large  public  eleemosynary  institutions.  But  it  is  quite 
equally  true  that  in  almost  every  case,  at  least  in  the  larger  hospitals,  where  a 
superintendent  is  found  peculiarly  unfit  for  the  position  he  holds,  he  is  less  of  an 
administrator  of  the  institution  than  a  specialist  in  some  department  of  the 
institution  work.  In  other  words,  scientific  specialization  in  a  hospital  superin- 
tendent is  diametrically  opposed  to  an  even,  intelligent  administration  of  all  the 
departments. 

Most  of  us  have  heard  hospital  trustees  excuse  themselves  for  having  at  the 
head  of  their  institution  an  incompetent  man  or  woman,  by  the  statement  that  the 
institution  is  small  and  that  they  could  not  afford  a  higher  salaried  official.  Natu- 
rally, the  question  will  be  asked  whether  an  inefficient  and  incompetent  superin- 
tendent is  not  an  expensive  official  at  any  price,  and  in  sequence  it  naturally  follows 
that  if  a  thoroughly  competent  superintendent  can  increase  the  efficiency  of  his 
institution  by  modern,  up-to-date,  scientific  methods,  and  improve  its  economy  by 
careful  buying  of  supplies,  by  a  thorough  knowledge  of  the  commodities  with 
which  the  institution  has  to  deal,  then  such  an  efficient  officer  is  cheap  at  almost 
any  price.  The  difference  between  a  $1000  superintendent  and  a  $3000  superintend- 
ent for  even  a  small  institution  can  be  wiped  out  by  an  economy  or  an  efficiency 
in  perhaps  two  or  three  directions,  and  if  then  the  more  expensive  official  can  be 
utilized  in  all  the  departments  of  the  institution,  what  a  great  saving  there  will  be 
in  administration,  and  what  greater  efficiency  must  come  from  such  a  policy. 
If  this  great  difference  is  to  be  found  in  small  institutions,  that  must  weigh  their 
dollars  and  their  pounds  carefully  to  see  that  the  one  offsets  the  other,  how  much 
greater  will  be  the  difference  in  the  administration  of  large,  costly,  expensively 
conducted  institutions!  The  superintendent  of  a  large  hospital  who  draws  $3000 
per  year  can  easily  waste  another  $3000  by  indifferent  purchase  of  supplies,  by 
wastefulness  in  the  use  of  his  commodities;  and  when  we  add  to  this  inefficiency 
on  the  part  of  the  low-salaried  official  in  the  scientific  work  of  the  institution  we 
have  a  comparison  that  will  hardly  admit  of  argument.  Most  hospital  boards 
of  directors  are  coming  to  take  this  view,  and  it  is  the  rule  rather  than  the  excep- 
tion that  hospital  superintendents  are  drawing  larger  salaries  than  ever  before, 
and  that  more  is  expected  of  them.  The  direct  consequence  of  this  is  that  whereas 
in  the  old  days  members  of  the  medical  staff  were  constantly  harassing  the  super- 
intendent of  their  institution  for  new  things,  new  apparatus,  new  methods,  nowadays 
it  is  the  other  way  about,  that  the  hospital  superintendent  under  the  new  order  of 
things  is  suggesting  new  methods,  new  apparatus,  and  is  giving  new  inspiration  to 
the  medical  staff  wholly  within  the  realm  of  administration. 

If  the  hospital  superintendent  is  to  really  superintend  the  activities  of  the 


THE    SUPERINTENDENT   OF   THE   HOSPITAL  255 

institution  over  which  he  presides,  and  if  those  activities  are  to  continue  along  the 
present  lines  of  progress  and  scientific  achievement,  it  seems  to  be  almost  a  self- 
evident  necessity  that  he  or  she  must  be  a  person  with  medical  training,  not  neces- 
sarily that  he  should  do  any  part  of  the  scientific  work,  but  that  he  should  know  how 
it  ought  to  be  done,  and  how  to  equip  the  institution  with  the  facilities  for  doing 
it.  Moreover,  if  the  hospital  administrator  is  to  be  the  actual  head  of  the  insti- 
tution these  days,  when  the  open-door  policy  is  becoming  general,  and  if  there  is 
to  be  any  sort  of  supervision  of  the  scientific  work  of  invited  physicians,  then  it 
would  seem  even  more  necessary  that  the  hospital  administrator  be  a  person  of 
medical  training.  Let  us  take,  for  instance,  a  general  hospital  that  has  an  organ- 
ized medical  staff  in  the  several  departments,  but,  under  the  policy  fixed  by  the 
board  of  directors,  invites  outside  physicians  to  participate  in  the  activities  of  the 
institution:  let  us  suppose  that  a  surgeon  in  the  community,  or  at  least  a  physician 
who  considers  himself  a  surgeon,  asks  for  the  privileges  of  the  surgical-operating 
department,  and  has  a  private  patient  on  whom  to  operate.  The  institution  has 
perhaps  published  the  fact  that  any  reputable  physician  in  the  community  may 
bring  his  patients  there.  It  would  seem,  in  such  a  case,  almost  impossible  to  deprive 
a  reputable  physician  of  the  privileges  of  the  hospital,  and  the  courtesies  of  the 
institution  are  extended  to  him  and  he  performs  the  surgical  operation  required. 
At  the  end  of  the  procedure  it  is  ascertained  that  the  physician  not  only  made  an 
inexcusable  blunder  in  the  diagnosis  of  his  case,  and  perhaps  operated  unnecessarily, 
but  that  he  did  the  operation  in  such  an  unworkmanlike  manner  that  his  patient 
became  infected  and  eventually  died.  In  such  a  case,  it  goes  without  saying,  the 
operator  ought  to  be  forbidden  thereafter  to  do  a  surgical  operation  in  that  institu- 
tion, but  the  surgical  members  of  the  staff  have  a  peculiar  delicacy  in  the  matter. 
If  they  ask  that  the  operator  be  excluded,  it  may  be  suggested  that  their  course  is 
actuated  by  personal  reasons;  that  they  fear  the  competition  of  the  newcomer. 
If  they  approve  of  his  continuing  to  operate,  they  can  clearly  be  accused  of  condon- 
ing^in  offense  that  means  the  lives  of  human  beings;  so  that,  no  matter  what  posi- 
tion"the  existing  surgical  staff  may  take,  the  situation  of  the  members  will  be  a 
most  embarrassing  and  unpleasant  one.  But  suppose,  for  instance,  the  institution 
has  at  its  head  a  competent  medical  administrator,  one  who  is  not  in  active  practice, 
and  who  has  at  his  command  for  counsel  a  corps  of  medical  men  quite  capable  of 
advising  him  as  to  the  actual  occurrences  during  the  course  of  the  operation  we 
have  outlined.  No  one  can  accuse  the  superintendent  of  interested  motives  or 
personal  prejudice;  if  he  invites  the  offending  operator  into  his  office  and  states 
merely  the  facts  of  the  case,  and  then,  kindly  and  courteously,  but  firmly,  informs 
the  operator  that  because  of  his  unskilful  methods  he  is  asked  to  discontinue  opera- 
tive work  in  the  hospital,  no  fault  in  such  a  case  can  be  found,  at  least  no  personal 
motives  can  be  adjudged.  In  any  event,  a  hospital  presided  over  by  such  an  admin- 
istrator will  not  likely  become  involved  in  disreputable  professional  practices,  and 
it  would  seem  that  such  a  superintendent  had  not  gone  too  far  in  protecting  his 
institution  and  his  medical  staff,  as  well  as  the  public  at  large,  from  the  imposition 
of  unskilful  professional  work.      He  will  be  criticized,  of  course,  but  hardly  justly. 

Relations  to  the  Board  of  Directors. — The  superintendent  of  the  institution 
being  the  executive  officer  of  the  board  of  directors,  it  is  his  duty  to  carry  out  to 
the  best  of  his  ability  the  wishes  and  policies  and  the  rules  and  regulations  of  those 
to  whom  he  must  look  for  his  orders. 

If  it  is  the  duty  of  the  superintendent  to  carry  out  the  orders  of  his  board,  it  is 
certain  that  he  cannot  divest  himself  of  the  additional  duty  to  give  to  his  hoard  and 
to  the  institution  his  best  abilities  in  the  way  of  advice  and  counsel.     He  is  sup- 


256  OPERATION   OF   THE    HOSPITAL 

posed  to  be  an  expert  in  the  management  of  such  an  institution,  and  as  such  he  is 
expected  to  know  how  things  should  be  done,  and  he  should  be  expected  to  give  the 
benefit  of  his  knowledge  to  those  by  whom  he  is  appointed,  by  whom  he  is  paid,  and 
to  whom  he  is  responsible.  If  the  relationship  between  the  superintendent  and  the 
board  of  directors  is  to  be  a  pleasant  one  to  all  parties,  as  well  as  a  profitable  one  to 
the  institution,  it  goes  without  saying  that  there  should  be  the  greatest  possible 
frankness  and  confidence  between  the  board  and  its  superintendent.  The  members 
of  the  board  owe  it  to  the  superintendent  and  to  the  institution  to  deal  fairly 
with  him,  to  keep  back  nothing  that  can  help  him  in  his  office  as  administrator. 
If  they  find  that,  according  to  their  judgment,  he  is  falling  short  of  what  such  an 
officer  ought  to  be  it  is  their  duty  to  tell  him  so.  If  they  find  that  their  superin- 
tendent is  drifting  away  from  the  moorings  which  they  have  built  and  to  which 
they  wish  the  institution  still  to  cling,  they  ought  to  point  out  to  him  the  weakness 
of  his  position  in  detail  and  to  insist  upon  a  change. 

On  the  other  hand,  if  the  superintendent  of  an  institution  is  to  be  happy  and 
comfortable,  and  is  to  be  efficient  and  give  to  the  institution  the  benefit  of  all  the 
ability  he  possesses,  he  is  entitled  to  the  confidence  of  his  board  of  directors  and  to 
an  appreciation  of  that  confidence  when  occasion  offers.  If  the  superintendent 
finds,  at  any  time,  that  he  is  apparently  out  of  touch  with  his  board,  or  with  a 
faction  of  the  board,  it  ought  to  be  his  privilege  to  say  so  frankly,  so  that  there  may 
come  a  better  understanding,  and  so  that  any  apparent  difficulties  may  be  ad- 
justed. 

The  question  often  comes  up  whether  a  hospital  superintendent  ought  to  attend 
the  meetings  of  the  board  of  directors.  Perhaps  that  question  cannot  be  answered 
for  individual  cases,  and  it  would  seem  that  while  a  superintendent  is  new,  and  while 
his  status  with  his  board  of  directors  is  rather  unsettled,  and  while,  perhaps,  the 
members  wish  to  feel  free  to  discuss  him  and  his  acts  without  his  being  present,  the 
superintendent  might  very  well  absent  himself  from  meetings  of  his  board,  and  the 
invitation  for  him  to  be  present  should  certainly  come  through  the  board  to  him, 
and  not  vice  versa.  It  would  seem  that,  if  a  board  of  directors  is  to  have  the  great- 
est possible  benefit  of  the  knowledge  and  judgment  of  its  superintendent,  he  ought 
to  be  present  during  the  discussion  of  things  apropos  of  hospital  administration, 
so  that  he  may  offer  a  suggestion  here  and  a  bit  of  information  there,  and  certainly, 
under  such  conditions,  there  will  come  a  wiser  and  safer  settlement  of  problems  if 
the  superintendent  is  taken  into  the  confidence  of  his  board  of  directors  than  where 
the  board  must  act  on  its  own  initiative,  and  without  that  intimate  information 
that  the  superintendent  of  the  hospital,  always  attending  to  the  duties  of  the  insti- 
tution, could  give. 

It  has  been  frequently  stated  by  members  of  a  board  that  they  would  like  to 
have  their  superintendent  present,  but  that  sometimes  they  will  want  to  discuss 
matters  with  which  he  is  not  concerned,  or  in  which  he  is  personally  involved,  and 
that,  if  he  is  expected  to  be  present  continuously,  they  will  not  have  the  privilege 
of  perfect  freedom.  It  would  seem  that  this  is  a  mistaken  view.  Every  sensible 
hospital  administrator  must  know  that  at  times  he  is  under  discussion — his  methods, 
his  personality,  and  his  conduct — and  it  is  equally  sure  that  such  a  man  must  under- 
stand that  the  board  will  want  to  be  unembarrassed  by  his  presence  while  such 
things  are  under  discussion,  so  that,  if  there  is  that  utmost  frankness  that  there 
ought  to  be  between  the  board  and  its  executive  officer,  it  should  be  an  easy  matter 
for  the  president  of  the  board,  or  any  member,  to  merely  hint  that  the  absence  of 
the  superintendent  is  desired;  or  a  member  of  the  board  ought  to  feel  free  to  sug- 
gest that  he  would  like  to  bring  up  a  matter  that  is  rather  personal  to  the  super- 


THE   SUPERINTENDENT   OF  THE    HOSPITAL  257 

intendent,  and  that  he  would  like  to  have  it  discussed  by  the  board,  and  that,  there- 
fore, he  would  like  to  request  that  the  superintendent  absent  himself.  If  this  com- 
mon ground  were  definitely  understood  between  the  board  and  the  superintendent, 
it  ought  to  make  things  very  much  easier  from  every  view-point.  Of  course  there 
is  the  other  view,  too:  the  superintendent  ought  to  have  the  privilege  of  excusing 
himself  for  attendance  on  any  meeting  of  his  board  if  his  duties  call  him  elsewhere, 
or  if  it  is  inconvenient  for  him  to  be  present,  and  if  there  is  perfect  confidence 
between  the  board  and  its  executive  officer,  such  an  explanation  ought  to  suffice 
to  free  him  from  any  possible  thought  in  the  minds  of  the  board  that  he  has  some 
ulterior  motive. 

Relation  of  the  Superintendent  to  Attending  Men. — If  the  superintendent  of 
the  hospital  is  the  executive  officer  of  the  board,  and,  if  the  board  of  directors  is 
responsible  for  the  conduct  of  the  institution  in  every  part,  then  it  naturally  follows 
that  the  superintendent  must  be  the  director  of  the  hospital's  affairs  in  the  absence 
of  the  board.  If  there  are  established  rules  for  the  conduct  of  the  medical  men  in 
the  institution,  of  course  it  will  be  the  duty  of  the  superintendent  to  see  that  those 
rules  are  enforced,  as  an  expression  of  the  policy  fixed  by  the  board  of  directors; 
in  some  institutions  there  are  such  rules  worked  out  pretty  much  in  detail,  and  the 
superintendent  of  such  an  institution  will  have  rather  easy  sailing  in  keeping  the 
members  of  the  medical  profession  within  the  limits  of  the  rules.  But  such  insti- 
tutions are  not  the  ones  that  progress  the  most  or  diverge  into  the  broadest  work. 
They  are  rather  narrow  in  their  activities,  and  there  is  not  very  much  encourage- 
ment in  iron-clad  rules,  either  for  the  members  of  the  medical  staff  or  for  the 
superintendent  of  the  hospital,  to  branch  out  into  new  fields  of  activity  and  to  es- 
tablish new  standards  when  they  constantly  feel  the  confinement  of  despotic  rules. 

Most  institutions,  however,  do  not  have  printed  rides  for  the  conduct  of  visiting 
medical  men;  medical  men  resent  iron-clad  rules.  There  is  an  air  of  subservience 
in  being  held  within  the  narrow  limits  of  rules,  and  where  there  are  no  specific  rules, 
but  general  policies,  there  is  present  a  constant  incentive  to  the  visiting  medical 
men  to  work  out  progressive  ideas.  And  it  is  in  such  an  atmosphere  as  this  that  a 
superintendent  will  find  his  best  inspirations.  He  is  not  the  servant  of  the  medical 
staff  or  the  medical  men,  nor  is  he  their  master.  His  position  is  one  of  responsi- 
bility for  the  care  of  patients  in  the  institution,  no  matter  who  the  doctor  may  hap- 
pen to  be.  In  other  words  he  is  a  consultant,  so  to  speak,  in  every  case  in  the 
hospital,  and  his  specific  duty  is  to  provide  the  necessary  facilities  for  the  doctor  in 
the  treatment  of  the  patient — not  alone  to  provide  what  the  doctor  wants,  but  to 
suggest,  if  he  can,  new  ideas  that  are  within  the  reach  of  the  institution  and  of  the 
presence  of  which  the  doctor  is  perhaps  not  informed. 

The  greatest  incubus  to  an  ambitious  hospital  superintendent  is  subserviency, 
either  to  a  personality,  a  faction,  or  a  factor  in  the  administration  of  the  hospital. 
In  the  first  place  he  ought  to  feel  that  his  judgment  in  any  given  case  is  final. 
There  are  many  institutions  in  which  there  is  a  definite  understanding  that  the  board 
of  directors  will  support  its  superintendent  in  any  decision  he  may  make;  sometimes 
his  decision  will  not  accord  with  the  views  of  the  board  of  directors,  and  some- 
times he  will  be  wrong  without  any  question,  but  every  principle  of  discipline  would 
be  violated  if,  after  the  superintendent  had  made  a  decision  in  a  case  affecting  one 
or  more  members  of  the  medical  profession,  the  board  of  directors  were  to  reverse 
his  decision,  so  that  the  wise  board  will  always  support  its  superintendent,  right  or 
wrong.  If  the  superintendent  should  be  repeatedly  wrong  in  his  decisions,  and 
should  make  those  decisions  so  binding  that  his  board  would  have  cither  to  decide 
for  him  or  against  him  in  an  uncompromising  manner,  his  position  would  become 

17 


258  OPERATION    OF   THE    HOSPITAL 

very  soon  untenable,  and  he  would  be  guilty  of  so  gross  a  violation  of  good  diplo- 
macy and  tact  that  the  board  would  have  to  make  him  understand  that  he  would 
either  have  to  decide  questions  tentatively  and  put  the  final  decision  up  to  the  board, 
or  he  would  have  to  be  replaced  by  some  one  of  more  tact  and  judgment.  If 
it  became  known  that  a  member  of  the  medical  staff,  or,  indeed,  if  it  became 
known  that  any  factor  in  the  hospital  administration  could  overturn  a  decision  of 
the  superintendent  by  an  appeal  to  the  board  of  directors,  the  superintendent's 
mastery  of  the  affairs  of  the  hospital  would  be  at  an  end  and  his  usefulness  gone. 

The  wise  superintendent,  who  has  the  confidence  of  his  board  of  directors,  will 
naturally  also  have  the  confidence  of  the  members  of  the  medical  profession  and  of 
the  public  and  of  the  patients,  because  his  inherent  qualities,  that  have  given  him 
the  confidence  of  his  board,  will  have  brought  confidence  in  other  fields,  and  such  a 
man  will  naturally  maintain  that  confidence  by  calm  deliberation  in  his  judgment, 
by  fair  decisions,  and,  above  all,  by  a  square  deal  to  everybody. 

If  there  is  to  be  harmony  between  the  various  factors  in  the  operations  of  an 
institution,  the  superintendent  must  be  the  pivot  around  which  that  harmonious 
operation  must  revolve;  and  the  very  key-note  in  the  creation  of  such  harmony 
will  be  an  established  feeling  on  every  hand  that  there  is  no  favoritism,  and  that 
every  one  at  all  times  is  secure  in  obtaining  exact  justice.  If  the  medical  men 
feel  that  one  of  their  number  can  get  about  what  he  wants,  and  if  there  are  other 
medical  men  who  feel  that  there  is  an  element  of  favoritism  in  the  conduct  of  the 
affairs  of  the  hospital  at  the  hands  of  the  superintendent,  harmony  will  be  at  anN 
end;  friction  is  sure  to  follow.  There  will  come  every-day  problems  in  the  medical 
care  of  patients,  and  in  the  medical  and  surgical  operations  of  the  hospital  gen- 
erally, and  nearly  always  these  problems  will  involve  the  personal  interests  of  those 
whom  they  affect.  If  the  medical  men  themselves,  by  way  of  their  staff  organiza- 
tion or  by  way  of  the  personal  strength  and  influence  of  certain  members  with 
members  of  the  board  of  directors,  are  compelled  to  settle  their  own  problems,  there 
will  grow  up  a  species  of  hospital  politics,  one  of  the  most  insidious  cancers  in  an 
institution,  and  an  evil  that  will  do  more  harm  than  almost  any  other.  But  sup- 
pose, for  instance,  that  there  is  a  superintendent  on  the  ground  who  has  a  knowl- 
edge of  medical  ethics,  who  appreciates  the  relationship  between  medical  men  toward 
each  other  and  between  the  medical  men  and  the  public,  and  who  can  be  counted 
on  to  make  a  wise,  diplomatic,  and  judicious  disposition  of  perplexing  problems 
that  arise!  To-day  such  a  decision  may  hurt  one  man,  to-morrow  it  may  favor 
him.  At  the  time  the  decision  is  made  the  person  against  whom  it  lies  will 
naturally  feel  disgruntled,  but  if  the  decision  has  been  of  such  character  that  he  can 
feel,  on  sober  second  thought,  after  the  personal  interest  phase  has  disappeared, 
that  the  decision  has  been  for  the  best  good  of  the  institution,  and  consequently 
for  the  best  good  of  all,  it  will  not  be  long  before  such  a  superintendent  has  the 
entire  confidence  of  everybody,  to  the  end  that  his  decisions  will  become  effective 
without  protest,  and  then,  and  then  only,  can  there  be  considered  a  harmonious 
administration  of  an  institution. 

Sometimes  in  the  smaller  hospitals,  where  there  is  an  inadequate  or  incompetent 
medical  service  in  one  or  other  of  the  departments,  it  may  become  necessary  under 
certain  conditions  for  the  superintendent  to  take  a  professional  part  in  the  care 
of  patients,  and  such  a  superintendent's  duties  will  be  onerous  in  the  extreme  and 
his  difficulties  great.  His  attitude  will  be  that  of  a  competing  practitioner,  in  a 
sense,  attempting  to  give  equal  justice  to  himself  and  to  the  members  of  the  staff, 
his  natural  competitors.  Those  of  us  who  have  had  large  experience  in  institu- 
tional work  will  search  the  past  in  vain  for  an  example  of  an  institution  where  the 


THK   SUPERINTENDENT  OF   THE    HOSPITAL  259 

superintendent  is,  at  the  same  time,  a  part  of  the  medical  staff  and  superintendent 
of  the  institution,  and  whose  administration  has  been  harmonious  and  successful. 

The  superintendent  of  any  hospital  ought  to  keep  in  touch  with  the  advances 
in  the  medical  profession.  He  ought  to  know  the  new  discoveries  and  about  the 
invasion  of  new  fields,  and  he  ought  to  be  well  grounded  in  the  fundamental 
principles  of  the  science,  so  that  in  any  case  that  may  arise  he  will  be  able  to  dis- 
cover the  difference  in  a  medical  attendant  between  the  wheat  of  practical  things 
and  the  chaff  of  an  enthusiasm  that  is  not  balanced  by  sound,  practical  sense. 

Almost  daily  members  of  the  medical  profession  are  appealing  to  the  progressive 
superintendent  of  the  hospital  for  new  apparatus,  or  new  methods  of  procedure,  or 
new  activities  along  some  scientific  line.  If  the  superintendent  says  "no"  on  general 
principles,  and  continues  to  say  "no,"  to  these  constant  demands  of  the  profession, 
his  attitude  will  throw  cold  water  upon  many  deserving  propositions  and  many 
deserving  features  of  hospital  conduct.  On  the  other  hand,  if  he  says  "yes"  to  every 
proposition,  he  will  shipwreck  his  administration  on  the  rocks  of  extravagance. 
So  that,  again,  he  must  fall  back  upon  a  common-sense  and  administrative  wisdom, 
coupled  with  a  sound  knowledge  of  what  is  going  on  in  the  medical  profession. 

There  are  certain  phases  of  hospital  administration  in  which  superintendents 
must  be  guided  by  the  greater  wisdom,  or,  rather,  the  more  specialized  wisdom  of 
members  of  the  medical  profession;  and  the  wise  superintendent  will  divide  his 
responsibilities  many  times,  not  with  a  single  confidential  adviser  or  an  intimate 
personal  friend  in  the  medical  corps,  but,  as  each  problem  arises,  he  will  divide  his 
responsibilities  with  the  particular  member  of  the  medical  corps  that  would  seem, 
from  his  position,  to  be  the  safest  guide  in  that  particular  direction.  It  is  perhaps 
a  question  of  isolation  in  the  children's. department,  and  there  will  be  one  particular 
man,  perhaps  the  chief  of  the  pediatric  section,  whose  experience  and  judgment  will 
be  the  best  in  such  a  case,  and  the  wise  superintendent  will  counsel  with  such  a  man 
and  follow  his  advice.  Perhaps  it  is  a  case  of  erysipelas  in  a  surgical  patient. 
The  attending  surgeon  in  the  case  may  not  be  the  best  judge  as  to  what  should  be 
done,  because  his  interest  in  his  own  patient  may  obscure  somewhat  his  judgment 
as  to  what  would  be  best  for  the  institution  as  a  whole,  but  there  will  be  some  un- 
prej  udiced  member  of  the  surgical  staff  who  can  think  clearly,  because  disinterestedly, 
in  that  particular  case.  At  any  rate,  before  taking  any  radical  action,  the. super- 
intendent can  have  the  advantage  of  such  advice  before  proceeding  to  a  course  that 
may  work  harm  in  some  direction.  And  so  we  might  carry  problems  through  all 
the  departments  of  the  institution,  and  find  a  different  adviser  for  the  settlement 
of  each.  And  if  it  becomes  generally  known  among  the  medical  men  that  the  super- 
intendent has  a  habit  of  seeking  the  advice  of  disinterested  members  from  their  own 
number  in  the  settlement  of  current  problems,  such  knowledge  will  add  to  the 
confidence  in  the  wisdom  of  the  administration  of  the  institution.  On  the  other 
hand,  if  it  becomes  known  that  the  superintendent  of  the  hospital  is  seeking  counsel 
and  taking  the  advice  of  one  member  of  the  corps,  or  of  one  coterie,  on  all  problems 
that  arise,  this  again  will  give  rise  to  hospital  politics  of  a  most  hurtful  character. 
which  will  have  for  its  end  the  discrediting  of  the  activities  of  the  superintendent, 
and  the  best  that  can  be  looked  for  under  such  conditions  will  be  an  unharmonious 
conduct  of  affairs. 

It  takes  courage  to  administer  the  affairs  of  a  hospital,  and  to  maintain  control, 
on  the  part  of  the  superintendent.  Where  men's  interests  are  involved  their  activ- 
ities will  lie  great,  and  oftentimes  they  will  employ  every  art  i  lice  and  every  influence 
that  can  be  brought  to  bear  to  succeed  in  their  purposes,  and.  if  the  hospital  super- 
intendent shows  the  least  weakness  under  such  pressure,  his  influence  will  be  de- 


260  OPERATION   OF   THE   HOSPITAL 

stroyed;  so  that  he  ought  to  be  especially  careful  in  making  his  decisions,  in  order 
that  under  pressure,  and  iD  the  face  of  any  opposition,  he  will  be  able  to  maintain 
his  position  against  a  member  or  the  whole  medical  corps. 

Relation  of  the  Superintendent  to  Interns. — The  superintendent  of  the  insti- 
tution must  have  absolute  control  over  the  interns,  and  there  can  be  no  half-heart- 
edness  about  such  authority,  nor  can  written  rules  and  fixed  practices  be  waived 
for  an  instant.  These  young  men  are  at  a  period  of  their  lives  where  they  rebel 
the  greatest  against  constituted  authority,  and  where  their  judgment  is  not  good 
enough  to  be  entrusted  with  discretion.  In  a  hospital  where  intern  services  rotate, 
and  where  an  intern  that  is  serving  one  attending  physician  to-day  changes,  and  is 
under  another  jurisdiction  in  three  months  from  now,  it  naturally  follows  that  it 
will  not  be  best  for  the  medical  men  to  be  entrusted  with  authority  over  the  interns. 
Moreover,  the  medical  men  are  away  from  the  hospital  a  good  deal  of  the  time,  and 
these  young  men  must  be  entrusted  with  a  great  deal  of  responsibility  in  the  care 
of  patients,  and  there  must  be  some  ever-present  absolute  authority. 

Rules  cannot  be  worked  out  too  much  in  detail  for  these  young  men.  It  must 
be  definitely  stated  what  they  shall  do,  and  when  and  how;  even  the  details  in  their 
home-life  in  the  institution  must  be  specific,  and,  after  all  is  said,  they  will  be  suc- 
cessful or  failures,  depending  on  whether  they  are  compelled  to  obey  definite  rules. 
There  never  was  an  intern  corps  the  members  of  which  did  not  break  every  rule 
that  they  could  break  with  impunity.  In  other  words,  if  they  were  not  punished 
for  a  violation  of  the  rules  the  rules  soon  become  a  dead  letter.  In  many  institu- 
tions the  administration  has  started  out  on  the  assumption  that  the  interns  are 
young  physicians  and  men  of  honor,  and,  if  placed  on  their  honor,  they  would  live 
up  to  the  highest  expectations  that  could  be  fixed  for  them.  Those  who  have 
had  much  experience  with  interns  will  know  that  this  attitude  is  an  artificial  one 
and  that  it  is  not  successful.  The  young  men  may  be  gentlemen  of  the  highest 
moral  character,  their  home  training  may  have  been  correct  and  their  ideals  high, 
but  as  a  corps,  living  in  an  institution,  and  given  for  the  first  time  a  certain  limited 
authority,  glorified  by  the  title  of  doctor  of  medicine,  and  the  intern  has  yet  to  be 
born  who  does  not  lose  his  head,  become  self-opinionated,  arrogant,  and  sometimes 
even  dangerous.  So  that  in  every  successful  hospital  where  interns  are  employed 
the  rules  for  them  are  iron-clad,  and  are  lived  up  to,  and  if  this  is  to  be  the  status 
of  affairs  it  must  come  through  the  superintendent  of  the  institution. 

We  have  had  elsewhere  a  copy  of  rules  for  the  government  of  interns,  and  if  the 
superintendent  of  the  institution  shall  have  seen  to  it  that  these  young  men  obey 
these  rules,  he  will  not  only  get  the  best  service  possible  out  of  them,  but  he  will  be 
doing  more  for  them,  and  for  their  future  careers  as  medical  men,  than  by  any 
sentimental  course  of  conduct  that  places  them  upon  an  idyllic  plane,  and  that 
clothes  them  with  a  personality  and  a  personnel  that  they  do  not  yet  possess,  and 
will  possess  only  after  a  vast  amount  more  of  experience  in  buffetings  of  the  world. 

Relation  of  the  Superintendent  to  Nurses. — Whatever  opinion  the  superinten- 
dent of  a  hospital  may  hold  as  to  the  modern  training  of  nurses,  or  whatever  his 
attitude  may  be  toward  the  adequacy  of  modern  nursing  methods,  he  has  at  least 
a  definite  duty  to  the  patients  in  the  hospital  that  are  under  his  care,  and  that  is  to 
see  that  they  are  properly  nursed,  to  see  that  the  orders  of  physicians  and  house 
physicians  are  carried  out  in  a  competent,  prompt,  and  efficient  manner.  When 
this  is  done  he  may  invade  the  realm  of  speculation  as  to  modern  nursing  methods, 
the  training  that  is  at  the  present  time  prescribed  for  pupil  nurses,  and  those  other 
academic  problems  of  training-schools.  This  right  of  speculation  is  his  as  an  inter- 
ested observer  of  contemporary  things,  but  he  will  be  doing  less  than  his  whole 


THK    SUPERINTENDENT    OF    THE    HOSPITAL  2G1 

duty  unless  he  insists  upon  a  training  that  will  nurse  his  patients  efficiently.  Such 
training  is  not  being  given  to  nurses  at  the  present  time  in  any  school  in  this  country. 
If  they  are  efficient  and  skilful  with  their  fingers,  understand  medical  and  surgical 
technic,  and  are  otherwise  capable,  it  is  a  personal  fitness  other  than  one  resulting 
from  contemporary  training.  The  attitude  of  the  public  toward  trained  nurses 
at  this  time  is  too  well  known  for  this  statement  to  be  controverted. 

With  this  arraignment  of  a  somewhat  academic  character,  let  us  proceed  to  the 
actual  administration  of  the  average  institution  where  pupil  nurses  are  employed. 
Complaints  of  poor  nurses,  and  of  irresponsible  conduct,  and  of  still  more  irrespon- 
sible statements  of  nurses  to  their  patients,  of  injudicious  utterances — all  these 
come  to  the  superintendent's  office,  and  his  administration  is  held  accountable  for 
these  short-comings  whether  he  would  evade  this  responsibility  or  not.  If  a  pupil 
nurse  makes  a  mistake  that  costs  a  patient's  life  the  reflection  is  on  the  hospital, 
and  the  community  will  hold  the  hospital  and  its  administration  responsible  for  the 
wrong,  and  in  the  public  arraignment  of  such  wrong-doing  the  training-school  and 
the  nurse  will  not  be  mentioned.  So  that  it  is  not  only  the  duty,  but  well  within 
the  province  of  the  superintendent  to  insist  on  efficient  nursing. 

It  would  be  a  violation  of  good  discipline  for  the  superintendent  of  any  hospital 
to  attempt  to  deal  'with  the  nurses  individually.  He  must  make  himself  effective 
through  the  superintendent  of  the  training-school  or  not  at  all.  All  orders  should 
go  through  the  superintendent  of  the  training-school,  who  should  feel  that  she 
is  responsible  for  the  conduct  of  her  nurses.  It  goes  without  saying  that  the 
superintendent  who  happens  to  see  a  nurse  doing  a  wrong  thing  should  correct  her 
on  the  spot,  and  that  he  should  then  follow  up  this  correction  by  a  report  to  the 
head  of  the  training-school.  Whether  such  a  regime  of  nursing  is  successful  or 
not  will  depend  very  much  upon  the  relationship  between  the  superintendent  of 
the  hospital  and  the  head  of  the  training-school. 

It  is  unfortunate  that  in  many  institutions  the  training-school  has  arrogated 
to  itself  so  important  a  function,  that  it  has  come  to  dominate  the  administration 
and  to  supplant  good  nursing  by  a  regime  of  institution  politics,  in  the  presence  of 
which  good  administration  and  good  nursing  are  both  impossible. 

Relation  to  the  Business  Management. — The  superintendent  will  naturally 
have  charge  of  the  business  management  of  the  institution.  The  board  of  directors 
that  institutes  dual  authority  in  a  business  manager  and  a  medical  director  of  an 
institution  invites  disaster.  The  business  manager  of  such  an  institution  will 
naturally  look  to  his  own  success,  which  means  economy  in  expenditure.  The 
medical  director,  on  the  other  hand,  will  look  to  the  success  of  his  department  in  a 
scientific  way.  He  will  want  to  provide  good  food;  he  will  want  to  provide  adequate 
surgical  supplies,  instruments,  and  apparatus,  and  whatever  medicines,  serums, 
vaccines,  and  therapeutic  agents  may  be  called  for  in  the  modern  treatment  of 
diseases.  If  the  business  manager,  who  is  not  a  person  of  medical  knowledge,  and 
who  is  not  specially  interested  in  the  scientific  welfare  of  the  institution,  has  it  in 
his  power  to  veto  a  purchase  there  will  be  little  or  no  progress  in  the  institution. 
Methods  will  look  toward  economy  rather  than  efficiency.  Scientific  work  will  be 
minimized.  In  other  words,  the  institution  will  stand  still,  and  there  can  be  DO 
harmony  between  two  officers  whose  duties  are  so  antagonistic,  and  especially  if 
either  or  both  of  them  happens  not  to  be  broad-minded,  progressive  men.  On  the 
other  hand,  if  the  superintendent  of  the  institution  is  charged  at  once  with  all  the 
hospital's  activities,  and  held  responsible  alike  for  its  scientific  progress  and  its 
financial  economies,  it  will  be  in  his  interest  to  temper  his  ambitions  of  a  scientific 
character  with  his  financial  limitations. 


262  OPERATION    OF    THE    HOSPITAL 

In  a  large  institution,  where  the  duties  of  the  superintendent  are  onerous  and 
exacting,  there  will  naturally  be  an  accounting  department,  and,  in  a  general  way, 
this  branch  will  be  charged  with  the  collection  of  accounts,  and  with  the  watching 
of  the  expenditures,  with  the  checking  of  bills  and  the  like,  so  that  the  superintend- 
ent's duties  can  be  minimized  and  confined  to  a  general  supervision  of  fiscal  affairs, 
and  this  is  one  department  in  which  the  superintendent  can  be  greatly  aided  by  that 
particular  member,  or  that  particular  committee  of  the  board  of  directors,  charged 
with  the  finances  of  the  institution.  In  other  words  the  superintendent  of  the 
hospital  must  work  with  the  finance  committee,  and  if  this  is  done  harmoniously 
an  immense  amount  of  work  and  worry  will  be  taken  from  his  individual  shoulders. 

There  must  be  some  one  who  shall  have  discretionary  power  in  current  financial 
matters,  some  one  who  can  purchase  goods  for  immediate  use,  and  some  one  who 
shall  have  power  to  make  emergency  arrangements  with  a  pay  patient  in  the  insti- 
tution for  holding  a  bill  in  abeyance,  or  for  making  certain  deductions  in  an  account, 
or  a  certain  refund,  and  naturally  this  power  will  fall  to  the  superintendent,  subject 
always,  of  course,  to  the  supervision  and  control  of  the  board  of  directors. 

It  goes  without  saying  that,  if  the  superintendent  is  to  be  charged  with  the 
proper  administration  of  the  affairs  of  the  institution,  he  must  have  power  to 
employ  and  discharge  the  help,  and  this  power  should  be  absolute  and  final  for  the 
common  help,  and  he  should  always  have  power  to  suspend  any  one  working  in  the 
institution  until  such  time  as  the  board  of  directors  may  investigate  and  make 
final  decision  upon  the  matter. 

Relations  to  Patients  and  the  Public. — The  relations  of  the  superintendent  of 
the  hospital  to  patients  and  the  public  may  be  considered  as  one  problem.  It  is 
a  delicate  relationship.  His  function  in  the  hospital  is  to  give  a  high  order  of  care 
to  patients,  and  in  doing  this  he  will  give  the  greatest  possible  amount  of  satis- 
faction to  the  relatives,  who  may  be  considered  to  represent  the  public.  It  is  the 
duty  of  the  superintendent  to  investigate  all  complaints  of  patients  or  their  rela- 
tives as  to  abuses  in  the  institution,  and  to  correct  these  when  found.  It  is  the 
superintendent's  duty  to  meet  the  relatives  of  patients  and  individuals  who  may 
be  interested  in  their  welfare,  and  to  discuss  their  anxieties  with  them,  and  to 
help  them  by  his  advice  in  every  way  possible,  and  the  most  delicate  of  all  his 
duties  will  be  sometimes  to  adjust  the  attitude  of  patients  and  their  friends  toward 
their  medical  adviser.  Oftentimes  a  complaint  will  be  made  to  the  superintendent 
of  the  institution  that  the  patient  is  not  getting  proper  medical  treatment,  and 
there  will  sometimes  be  coupled  with  this  complaint  a  demand  for  another  doctor, 
or  for  consultation,  and  in  such  contingencies  the  success  or  failure  of  the  super- 
intendent to  be  of  assistance  to  his  patient,  or  his  patient's  family,  will  depend  very 
much  upon  his  relation  to  the  members  of  the  medical  corps.  If  he  is  on  such  terms 
with  these  medical  gentlemen  that  he  can  go  to  them  in  a  confidential  capacity, 
and  represent  the  patient,  or  the  patient's  friends,  in  voicing  a  complaint,  he  can 
be  of  aid  both  to  the  physician  and  the  patient.  He  can  sometimes  bring  about  a 
new  stimulus  to  the  physician  in  the  treatment  of  the  patient,  and  sometimes  his 
consultation  with  the  physician  will  enable  him  to  assure  the  patient  that  he  is 
getting  the  very  highest  order  of  professional  service,  and,  in  any  event,  he  can  be 
of  infinite  service  to  all  concerned. 


THE  MEDICAL  STAFF 

The  medical  staff  is  the  most  important  factor  in  any  hospital.  Upon  it  will 
depend  the  success  or  failure  of  the  institution.  We  may  operate  every  other  de- 
partment of  the  institution  along  the  most  highly  developed  business  lines;  we 
may  buy  supplies  with  the  greatest  possible  acumen  and  judgment;  we  may 
employ  excellent  people  and  work  them  to  the  best  possible  advantage.  Every 
feature  of  the  operation  of  the  institution,  its  technic,  its  specialties,  its  care  of 
patients,  may  be  of  the  highest  order,  but,  unless  the  medical  staff  is  right,  the 
institution  will  be  wrong,  because  the  members  of  the  medical  staff  are  responsible 
for  the  care  and  cure  of  patients,  and,  unless  their  orders  are  right,  patients  will 
not  be  treated  right,  and  so  the  institution  will  be  a  failure. 

Unfortunately  there  are  few  instances  and  few  institutions  in  which  the  medical 
staff  can  be  chosen  upon  a  practical  basis,  and  too  often  policy  and  politics,  social 
and  professional  necessity,  and,  above  all,  financial  necessity,  will  dictate  the 
creation  of  the  medical  staff. 

Oftentimes  it  is  the  medical  men  in  the  community  who  are  the  inspiration  for 
the  creation  of  the  hospital,  and  quite  as  often  that  inspiration  is  born  of  personal 
ambition,  a  desire  on  the  part  of  the  medical  men  to  build  up  an  institution  that  will 
serve  their  personal  interests.  Fortunately,  men  strong  enough  in  the  community 
to  bring  such  ambitions  to  a  successful  issue,  by  securing  sufficient  co-operation  of 
the  citizens  generally,  will  usually  be  big  enough,  and  broad  enough,  and  unselfish 
enough  to  want  the  institution  successfully  conducted,  even  though  their  own 
personal  interests  must  sometimes  be  set  in  the  background. 

It  is  difficult  enough  to  operate  successfully  a  hospital  born  of  personal  ambition, 
even  under  the  most  auspicious  conditions.  It  is  impossible  to  conduct  an  insti- 
tution successfully,  and  that  larger  success  is  meant  that  stands  for  the  greatest 
good  to  the  greatest  number,  when  the  man  behind  the  philanthropy  or  enterprise 
would  prefer  failure  of  the  undertaking,  as^'whole,  to  failure  of  his  own  personal 
aims.  _    _  <s. 

Sometimes  the  inspira}.iottJor  an  institution  will  come  from  the  citizenship  of  a 
community,  and  the  Cooperation  of  the  medical  men  is  obtained  at  a  later  day. 
Such  an  institution  promises  the  broadest  success,  because  it  may  count  on  the  de- 
voted interest  of  men  who  do  not  expect  to  gain  personally,  to  the  detriment  of  the 
institution  as  a  whole. 

We  may  take  it  as  axiomatic  that  no  institution  can  be  bigger,  or  broader,  or 
more  famous  than  its  medical  staff,  and  the  two  must  strive  hand  in  hand  for  the 
goal. 

The  movement  for  a  general  hospital  begins  with  the  appointment  of  a  board  of 
managers  or  trustees.  The  next  step  is  the  raising  of  money  to  const  ruct  and  conduct 
the  institution;  and  the  third,  the  creation  of  the  medical  staff.  What  this  medical 
staff  shall  be,  how  organized,  and  how  many  shall  be  appointed,  will  depend  wholly 
upon  the  character  of  the  institution  and  the  necessities  of  the  community.  Natu- 
rally, if  the  institution  is  to  be  one  for  a  special  purpose,  such  as  a  railroad  hospital. 
or  one  to  care  for  miners  or  mill  hands,  or  any  class  of  special  workers  in  a  com- 
munity, the  medical  staff  question  will  be  a  simple  one,  and  the  surgeon  or  physician 


264  OPERATION   OF   THE    HOSPITAL 

to  the  corporation  will  be  the  whole  medical  power,  besides  being  responsible 
for  the  business  conduct  of  the  institution.  In  such  a  case  the  surgeon  for  the 
corporation  will  have  his  resident  assistants,  one  of  whom  will  perhaps  care  for  the 
medical  and  another  for  the  surgical  cases,  and  others  the  special  departments, 
such  as  the  eye,  the  nose  and  throat,  and  the  genito-urinary  department. 

If  the  institution  is  a  large  general  hospital  in  a  metropolis,  the  question  of  a 
medical  staff  becomes  at  once  a  very  complex  one  and  is  fraught  with  many  diffi- 
culties. Some  large  contributor  may  have  a  protege  in  medicine,  whose  interests 
he  desires  to  forward.  If  a  religious  denomination  has  initiated  the  movement  for 
the  institution,  leading  members  who  happen  to  be  medical  men  will  have  to  be 
cared  for,  or  the  family  physician  of  one  or  more  church  trustees  must  have  recog- 
nition. Sometimes  a  corporation  which  may  be  powerful  in  the  community,  and 
has  no  hospital  of  its  own,  but  whose  employees  are  frequently  hurt,  will  under- 
take to  bear  a  considerable  part  of  the  financial  burden  of  the  new  institution.  An 
influence  of  this  kind  is  perhaps  the  most  vicious  one  that  can  well  be  imagined  in 
the  creation  of  a  hospital,  because  the  corporation  will  usually  insist  upon  the 
employment  or  appointment  of  physicians  or  surgeons  of  its  own  choosing,  men  who 
can  be  counted  upon  to  serve  its  interests,  which,  however,  will  nearly  always  con- 
flict with  the  best  interests  of  the  patients  the  institution  will  be  called  upon  to  serve. 
These  corporations  will  demand  that,  immediately  upon  the  reception  of  a  patient 
who  has  been  hurt  at  their  works,  the  physician  employed  by  them,  who  has  been 
placed  on  the  staff  at  their  instance,  shall  be  called  to  the  case.  A  physician 
who  has  gone  far  enough  to  allow  himself  to  be  appointed  under  such  conditions 
will  go  farther,  and  do  the  corporation's  further  bidding  by  attempting  to  force  a 
financial  settlement  with  the  patient  while  he  is  still  in  shock,  or  at  least  very  ill 
from  the  results  of  the  hurt.  It  may  be  said  again  with  emphasis  that  such  a 
condition  is  one  of  the  most  vicious  features  that  can  arise  in  connection  with  a 
private  or  semipublic  general  hospital  of  the  present  day.  "Ambulance  chasers" 
do  not  all  come  in  the  ambulance  with  the  patient.     Some  of  them  arrive  later. 

Let  us  now  turn  to  a  more  attractive  phase  in  the  creation  of  the  medical 
staff,  and  assume  that  the  board  of  trustees  is  inspired  by  high  motives,  and  for 
the  good  of  the  whole  community  and  for  the  patients.  In  such  a  case,  the  board 
will  first  determine,  with  the  aid  of  medical  men  on  whom  they  can  rely,  the  classes 
of  cases  to  be  treated  in  the  institution,  the  divisions  of  the  institution  into  depart- 
ments of  medicine,  and  the  probable  percentage  of  the  patients,  as  divided  among 
those  departments.  Next  will  be  the  actual  appointment  of  the  members  of  the 
staff  in  these  departments,  and  here  enters  another  question  that  must  be  met  and 
settled.  Shall  there  be  a  definite  head,  with  well-defined  powers,  in  the  medical 
staff,  and  shall  this  medical  organization  direct  all  the  medical  work  of  the  hospital, 
or  shall  the  board  of  trustees  itself,  through  its  executive  officer,  the  superintendent 
of  the  institution,  direct  all  the  activities  of  the  hospital,  medical  and  otherwise, 
and  shall  the  members  of  the  medical  staff  be  assigned  definite  work  in  definite 
positions,  with  the  intention  that  their  work  be  under  fixed  rules? 

It  may  well  be  doubted  if  a  hospital's  greatest  good  will  be  accomplished  if  the 
physical  management  of  the  institution  is  entrusted  to  the  members  of  the  medical 
staff  in  any  degree.  It  may  well  be  doubted  that  the  staff  or  its  individual  members 
occupy  positions  to  make  such  domination  effective  and  efficient.  The  medical 
man  is  usually  not  clothed,  in  the  people's  minds,  with  vast  business  acumen  or 
great  business  experience.  His  activities  are  professional  and  scientific,  and,  if 
he  be  successful,  his  time  will  usually  be  most  fully  employed  in  work  other  than 
superintending  the  buying  of  supplies,  or  hiring  of  help,  or  the  installing  of  equip- 


THE    MEDICAL   STAFF  205 

ment  for  a  hospital.  It  would,  therefore,  seem  a  better  arrangement  to  appoint, 
within  proper  limitations,  a  given  number  of  medical  men  to  perform  the  profes- 
sional work  of  the  institution,  their  authority  to  end  with  their  professional  ser- 
vice. 

As  a  rule,  a  good  deal  of  apparatus  and  equipment  are  demanded  in  most  of  the 
departments  of  the  hospital.  The  surgeon  will  need  special  apparatus;  the  medical 
man,  a  constantly  varying,  but  expensive  dietary;  both  of  them,  an  abundance  of 
nursing  and  individual  service.  The  eye  man  will  see  his  own  department  the  most 
important  in  the  institution,  and  its  requirements  the  greatest,  and  so  with  all  of 
the  other  departments  of  the  hospital.  So  that,  if  any  individual  member  or  a 
few  members  of  the  medical  staff  are  charged  with  the  decision  as  to  the  purchase 
of  supplies  and  the  general  conduct  of  the  institution,  it  is  likely  that  those  par- 
ticular men  will  look  after  their  own  special  needs,  somewhat  to  the  exclusion  of 
departments  with  which  they  are  not  familiar  and  in  which  they  are  not  personally 
interested. 

Let  us  proceed  to  the  appointment  of  a  medical  staff.  Medical  men  associated 
with  an  institution  can  generally  be  divided  into  three  classes:  First  will  be  those 
active,  scientific  men,  virile,  ambitious,  and  in  the  heyday  of  their  careers,  upon 
whose  shoulders  the  actual  work  of  the  institution  will  fall,  who  have  had  large 
experience,  but  who  have  not  yet  arrived  at  an  age  when  rest  and  meditation  are 
required.  Second,  the  older  members,  men  who  have  already  their  careers  behind 
them,  whose  experience  has  made  them  sought  in  consultation,  who  are  perhaps 
closely  allied  with  the  money-giving  power  of  the  institution,  whose  warm  sympathies 
are  with  it,  whose  age  and  busy  lives  for  the  past  few  years  have  prevented  their 
keeping  abreast  of  the  progress  of  the  day.  Third,  the  young  men  who  have  per- 
haps served  their  internships  in  the  institution,  or  whose  connections  are  closely 
allied  with  it,  who  are  beginning  their  careers,  who  have  had  little  experience  in 
actual  practice,  and  whose  education  so  far  has  been  theoretic  rather  than  prac- 
tical.    For  working  purposes,  these  classes  of  medical  men  ought  to  be  called: 

1.  The  service  staff. 

2.  The  consulting  staff. 

3.  The  adjunct  or  auxiliary  Staff. 

The  Service  Staff. — Undoubtedly  the  service  staff  of  the  hospital  will  be  com- 
posed of  the  active  professional  men  doing  work  in  it,  not  those  who  will  have 
private  patients  merely,  but  who  will  take  care  of  the  free  patients  of  the  insti- 
tution. It  is  assumed  that  every  member  of  the  medical  staff  will  have  the  right  to 
send  patients  to  any  department  in  the  institution,  and  to  treat  those  patients  as 
he  sees  fit,  although  they  may  naturally  and  scientifically  fall  under  another  depart- 
mental classification.  If  an  oculist  sees  fit  to  treat  a  case  of  fever,  the  patient 
being  a  private  one,  his  right  cannot  be  gainsaid,  so  far  as  the  institution  is  con- 
cerned. 

Three  questions  lie  uppermost  in  a  discussion  of  the  service  staff  of  the  hospital. 
One  concerns  the  method  of  appointment,  the  number  of  men  required  to  do  the 
work,  and  their  relations  one  to  another,  and  to  the  administrative  forces  of  the 
institution. 

There  are  really  two  methods  of  selection  of  a  medical  staff.  One  is  by  direcl 
appointment  by  the  board  of  trustees,  and  the  other  is  by  some  sort  of  competition. 
It  is  only  within  very  recent  years  that  this  second  process  has  achieved  any  promi- 
nence, and  whether  it  shall  be  ultimately  successful  remains  for  the  future  to  decide. 

About  the  first  method — that  is,  direct  appointment — there  is  very  little  t<>  be 
said.     The  board  of  trustees,  having  decided  upon  the  number  of  men  for  each  de- 


266  OPERATION   OF   THE    HOSPITAL 

partment  in  the  hospital,  proceeds  by  election,  or  in  any  way  it  may  see  fit  to  out- 
line, to  fill  the  various  positions.  Usually  a  nominating  committee  of  the  board 
fills  in  the  name  of  each  staff  member.  When  the  list  has  been  reviewed  by  the 
board,  the  latter  will  then  proceed  to  a  formal  election  of  the  men  decided  upon. 

In  filling  a  vacancy  in  an  already  established  hospital  the  method  may  be  the 
same,  excepting  that  it  is  a  proper  courtesy  to  the  medical  staff  for  the  board  to 
notify  the  staff  that  it  has  such  appointment  under  consideration,  and  to  ask  whether 
the  appointment  will  meet  with  the  approval  of  the  staff.  Medical  men  are  very 
loathe  to  interfere  in  such  a  case,  and,  if  they  do  so,  it  is  likely  to  be  because  there 
is  some  very  well-founded  doubt  as  to  the  fitness  of  the  proposed  new  member. 
Nor  is  there  any  ethical  reason  why  a  board  should  abide  by  the  wishes  of  the  staff 
concerning  the  appointment.  In  presenting  the  name,  the  board  ought  to  ask  the 
staff  to  confine  its  consideration  to  the  fitness  of  the  candidate  for  the  position,  and 
the  staff  should  not  be  allowed  to  go  into  and  act  upon  the  personal  relations  of 
members  or  a  single  member  to  the  proposed  appointee.  Medical  men  are  not 
free  from  those  personal  and  professional  jealousies  that  afflict  the  rest  of  mankind, 
and  it  not  infrequently  happens  that  a  board,  dissatisfied  with  a  department,  may 
wish  to  strengthen  it  by  the  infusion  of  new  blood.  The  old  members  may  resent 
the  inference  that  they  are  no  longer  satisfying  to  the  board,  and  in  that  spirit 
may  persuade  the  other  staff  members  to  side  with  them  and  to  withhold  their 
recommendation.  When  a  name  for  appointment  is  sent  to  the  staff  and  meets 
with  disapproval,  it  would  seem  that  the  board  is  entitled  to  know  the  reasons; 
and  that,  if  in  the  judgment  of  the  board,  it  is  due  to  some  unworthy  motive,  the 
man  ought  to  be  appointed  over  the  head  of  the  staff.  Some  medical  staffs  actually 
shrivel  up  from  dry  rot,  for  no  other  reason  than  that  they  have  been  able,  from  year 
to  year,  to  go  along  as  they  pleased,  and  without  any  other  incentives  than  their 
own  convenience  and  the  value  of  the  hospital  to  them  as  a  personal  asset.  And 
it  will  often  happen  that  the  only  way  to  wake  the  staff  up  will  be  to  infuse  new 
blood. 

Appointment  by  Competition. — The  new  way,  appointment  by  competition, 
is  a  much  mooted  method,  one  open  to  a  good  deal  of  criticism,  which,  however,  if 
successful,  will  result  in,  by  all  odds,  the  best  working  staff  for  the  institution. 
It  will  hardly  be  the  one  chosen  for  a  private  or  semiprivate  institution,  and  would 
seem  best  fitted  for  the  great  charity  hospitals  in  the  large  cities. 

The  most  illustrious  example  of  this  method  occurred  in  the  case  of  the  Cook 
County  Hospital  at  Chicago,  not  long  enough  ago  to  determine  its  success  or  failure. 
Staff  service  had  not  been  a  success.  There  had  been  much  looseness  in  method, 
absence  of  technic,  inattention  to  duty  on  the  part  of  the  staff  members,  indiffer- 
ence as  to  attendance,  and  a  general  atmosphere  of  professional  irresponsibility. 
Interns  had  been  permitted  to  do  much  of  the  work,  even  major  surgery,  and  many 
scandals  had  arisen. 

The  Board  of  Cook  County  Commissioners  finally  determined,  after  the  ques- 
tion had  been  discussed  at  length,  not  only  among  themselves  and  with  the  ablest 
medical  men  in  the  community,  but  in  the  public  press  and  among  citizens  generally, 
to  attempt  to  create  a  staff  by  competitive  examination. 

It  would  not  do  to  require  an  eminent  surgeon,  who  had  been  following  his 
branch  of  the  profession  for  perhaps  twenty  years,  to  pass  an  examination  in  chem- 
istry, or  clinical  medicine,  or  in  diseases  of  the  eye,  nor  would  it  do  to  require  a  medi- 
cal man  to  pass  an  examination  in  minute  anatomy;  so  it  was  agreed  that  there 
should  be  a  different  examination  for  applicants  in  the  different  departments;  for 
instance,  the  applicants  for  positions  as  staff  surgeons  were  examined  in  surgery, 


THE    MEDICAL    STAFF  267 

anatomy,  pathology,  and  physiology,  all  of  these  branches  coming  directly  into 
play  in  their  every-day  practice  and  in  their  particular  branch  of  the  profession. 
Nor  would  it  do  to  place  these  experienced  men,  of  long  practice  and  practical  work 
in  the  profession,  upon  the  same  plane  as  young  men  who  were  just  leaving  school, 
because  the  younger  men  would  have  the  literature  over  a  wide  range  at  their 
fingers'  ends,  but  would  have  had  no  experience  at  all  in  the  practical  operations 
of  their  branch  of  science.  Therefore,  it  was  decided  to  allow  40  per  cent,  out  of 
100  for  what  was  called  "experience,"  including  the  number  of  years  of  hospital 
experience  the  applicant  had  had,  his  connection  with  teaching  institutions,  the 
original  work  that  he  had  turned  out,  and  the  number  of  years  he  had  been  in 
practice.  Sixty  per  cent,  was  then  allowed  for  the  technical  answers  in  the  written 
examination. 

This  method  was  not  satisfactory  to  the  profession  at  large.  The  older  and 
more  experienced  surgeons  who  had  reached  prominence  in  the  community  hesi- 
tated to  measure  their  attainments,  either  in  theory  or  practice,  with  their  fellows 
in  a  contest  that  might  be  subject  to  a  good  many  of  the  vagaries  of  luck.  The 
young  men  protested  against  this  form  of  appointment  because  of  the  tremendous 
handicap  of  40  per  cent,  given  to  the  older  men;  but,  in  spite  of  the  extreme  pres- 
sure against  the  method,  it  was  finally  carried  out.  The  result  was  the  acquisi- 
tion of  a  medical  staff  of  active,  earnest,  practical,  experienced  men,  ambitious 
enough  to  have  entered  the  contest,  and  ambitious  enough  to  want  to  achieve  some- 
thing once  they  were  appointed;  and  the  staff  so  chosen  seems  to  be  one  of  the 
most  successful  that  has  ever  been  charged  with  the  professional  work  of  a  great 
hospital. 

One  of  the  questions  incident  to  this  contest  concerned  the  personnel  of  the 
examining  board.  It  was  settled  by  the  appointment  of  a  board  composed  of 
some  of  the  older  and  most  eminent  men  in  the  profession,  whose  lives  were  full 
of  honors,  and  whose  private  practices  required  so  much  of  their  attention  that  they 
had  neither  the  time  nor  inclination  to  devote  additional  time  to  public  work,  to 
which  they  had  already  given  so  many  years  of  their  lives. 

In  the  hospitals  affiliated  with  or  operated  in  conjunction  with  a  medical 
school  the  process  of  staff  building  is,  of  course,  different.  There  the  heads  of  depart- 
ments in  the  school  will  be  automatically  the  service  staff  members  of  the  hospital; 
and  we  might  pause  here  just  long  enough  to  suggest  that,  instead  of  its  being  detri- 
mental to  patients  to  be  used  as  clinical  material,  they  will  thereby  always  be  the 
greatest  gainers  by  such  use.  In  the  first  place,  the  cases  are  better  worked  up 
and  the  correct  diagnosis  more  eagerly  sought.  The  medical  attendants  give 
more  careful  attention  to  patients,  because  it  would  be  rather  embarrassing  for  a 
professor  to  have  some  bright  student  or  intern  "spot"  something  he  had  failed 
to  find.     So  the  patient  profits  to  that  extent. 

Number  of  Men  on  Service. — The  number  of  medical  men  to  be  distributed 
through  the  hospital  to  do  the  work  will  depend  on  several  conditions,  the  chief 
of  which  will  be  the  number  of  patients  in  the  several  services.  It  is  almost  an 
acknowledged  assumption  that  medical  men,  who  are  prominent  enough  to  deserve 
appointment  as  visiting  staff  members  of  a  large  general  hospital,  are  too  busy 
in  their  private  work  to  devote  more  than  say  two  or  three  hours  per  day  to  the 
institution  charity  work,  and  it  is  the  more  generous  of  the  men,  and  certainly  the 
more  ambitious  of  them,  who  will  continue  from  year  to  year  to  give  that  much 
time.  So  that  we  can  safely  calculate  upon  two  or  three  hours  per  day  as  the  limit 
of  service  to  be  expected  from  the  average  member  of  the  staff.  Some  departments 
of  the  hospital  will  require  a  good  deal  more  time  than  others.     It  is  said  that  a 


268  OPERATION   OF   THE    HOSPITAL 

patient  on  the  medical  service  cannot  be  properly  gone  over  for  physical  examina- 
tion in  less  time  than  an  hour.  If  there  is  a  good  intern  service  in  the  hospital, 
one  in  which  the  histories  are  efficiently  handled,  in  which  the  physical  examinations 
by  the  senior  house  staff  members  are  made  in  a  scientific  manner,  and  in  which 
the  laboratory  work  is  properly  done,  the  length  of  time  the  visiting  physician  will 
have  to  spend  will  be  very  materially  reduced,  and  he  ought  to  obtain  a  very  ex- 
cellent idea  of  the  average  case  in  fifteen  or  twenty  minutes.  There  will  be  obscure 
cases  in  which  he  will  have  to  go  over  the  patient  time  and  time  again,  but  even  in 
these  cases  he  may  be  so  puzzled  as  to  request  the  advice  of  some  member  of  an- 
other department  in  the  hospital,  and  thus  his  own  time  will  be  shortened  by  that 
much.  It  will  be  only  the  new  cases  in  the  hospital  that  will  require  as  much  as 
fifteen  or  twenty  minutes  of  the  attending  physician's  time.  A  good  many  of  his 
cases,  if  he  has  an  efficient  intern  service,  he  will  not  have  to  see  at  all  some  days, 
and  some  of  them  will  require  only  a  sufficient  amount  of  time  for  him  to  read  the 
house  physician's  daily  record,  and  the  nurse's  notes  of  temperature,  pulse,  respira- 
tion, feedings,  bowel  movements,  and  the  like,  in  all  a  matter  of  five  minutes.  In 
this  way  we  have  a  very  fair  idea  of  the  number  of  average  cases  the  average  phys- 
ician can  take  care  of  in  a  hospital  in  the  average  amount  of  time  that  will  be  ac- 
corded the  work.  We  have  been  contemplating  in  this  connection  the  medical 
services  of  the  hospital. 

The  surgical  department  will  not  differ  materially  as  to  time  occupied,  and 
amount  of  work  to  be  done,  if  the  proportion  of  patients  is  about  the  same.  Most 
surgeons  do  not  operate  every  day  on  service  cases,  but  twice  or  three  times  a  week, 
and  the  average  surgeon  will  spend  say  three  or  four  hours  in  the  operating-rooms, 
which  will  average  up  about  two  hours  a  day  for  the  week.  If  he  has  efficient  in- 
terns, he  will  rarely  need  to  see  his  convalescent  cases  in  the  wards  more  than  two 
or  three  times;  if  everything  goes  well,  and  if  the  dressing-room  service  is  prompt 
and  efficient,  he  should  not  lose  much  time  in  looking  at  the  wounds  of  the  cases 
it  is  necessary  for  him  to  see.  His  technic  will  soon  have  become  a  second  nature 
in  the  hospital,  and  his  methods  will  be  followed  as  a  routine  practice.  So  that  he 
will  spend  about  as  much  time  in  the  hospital  as  the  medical  man. 

The  attending  physicians  in  the  children's  department  will  spend  about  rela- 
tively the  same  amount  of  time  with  their  patients,  assuming  the  number  of  patients 
to  be  about  the  same  as  in  the  departments  which  we  have  already  discussed. 

The  specialties  are  a  vastly  different  matter.  If  the  hospital  is  in  a  metropolis 
where  the  school  rules  are  strict  about  tonsils  and  adenoids,  the  nose  and  throat 
men  may  have  a  good  deal  of  work  to  do,  their  cases  usually  coming  to  the  hospital 
with  a  diagnosis  already  made,  and  they  will  not  be  placed  in  the  attitude  of  con- 
sultants, so  they  can  immediately  proceed  with  their  work,  and  do  it  promptly. 

The  neurologist  will  not  have  so  many  cases,  in  fact,  in  the  average  hospital  will 
hardly  be  called  in  to  see  more  than  one,  or  at  most  two,  cases  per  day,  and  these 
in  a  consulting  capacity,  and  will  have  to  go  over  his  patients  very  thoroughly 
every  time.  Whether  or  not  his  service  shall  be  a  very  heavy  one  will  depend  not 
only  on  the  number  of  patients  in  the  hospital,  and  the  general  character,  class, 
sex,  nativity  and  environment  of  the  patients  as  bearing  upon  their  neuropathic 
peculiarities;  the  extent  of  his  service  will  also  depend  very  largely  upon  the  free- 
dom with  which  he  is  consulted  by  the  medical  men.  This  brings  into  the  fore- 
ground the  attitude  of  the  heads  of  those  respective  departments  toward  each  other. 

In  the  diseases  of  the  skin  and  of  the  eye  the  work  will  often  be  advisory, 
and,  unless  there  are  very  special  conditions  in  the  hospital,  those  services  will  not 
be  very  large,  and  the  visiting  men  will  hardly  be  called  to  more  than  one  or  two 


THE    MEDICAL   STAFF  209 

patients  at  each  visit.  Oftentimes  they  do  not  visit  the  hospital  regularly  at  all, 
because  of  the  infrequency  of  their  calls.  In  special  eye  and  skin  hospitals,  of  course, 
the  case  will  be  wholly  different,  and  the  men  will  be  heads  of  recognized  services; 
and  it  will  be  the  same  in  general  hospitals  that  have  special  eye  and  skin  depart- 
ments.    The  men  will  have  about  as  much  work  to  do  as  the  other  major  branches. 

These  foregoing  thoughts  will  lead  us,  in  a  large  measure,  to  a  conclusion  as  to 
the  number  of  medical  men  required  to  do  the  work  in  the  hospital.  The  question 
of  actual  work  to  be  done,  however,  is  not  the  only  one  involved  in  contemplating 
the  number  of  men  to  be  appointed  in  the  different  services. 

Permanent  or  Occasional  Service. — A  question  of  very  prime  importance  to  staff 
members  of  hospitals  everywhere  is  the  continuity  of  their  service.  A  good  many 
ambitious,  energetic,  high-class  men  are  connected  with  more  than  one  institution, 
it  being  their  purpose  to  be  on  service  at  one  or  the  other  institution  all  the  year 
round.  One  of  the  livest  topics  of  discussion  and  disagreement  between  boards  of 
trustees  and  medical  staffs  of  large  general  hospitals  concerns  the  continued  service 
of  the  members  of  the  staff  throughout  the  year,  and  from  year  to  year.  Medical 
men  greatly  object  to  being  on  service  for  two,  three,  or  six  months  of  the  year, 
and  then  retire  from  the  service  for  the  balance  of  the  year.  They  lose  touch  with 
the  institution  if  they  are  on  service  only  a  part  of  the  time,  unless  their  private 
patients  in  the  hospital  are  many.  They  forget  the  special  technic  of  the  hospital  ; 
they  forget  the  rules  of  the  institution,  and  they  even  forget  the  people,  unless  they 
are  constantly  brought  in  contact  with  them.  Besides  that,  they  nearly  all  try  to 
keep  up  to  date  in  the  literature,  and  they  like  to  have  material  with  which  to 
obtain  experience  with  new  methods,  new  lines  of  treatment,  new  surgical  opera- 
tions, so  that  nearly  every  medical  man  of  ambition  is  willing  to  make  a  good  deal 
of  a  sacrifice  in  the  extra  time  he  must  give  to  the  institution  to  take  care  of  the 
full  service  all  the  year  round,  in  order  to  keep  in  training,  as  it  were. 

From  the  standpoint  of  the  hospital  there  are  advantages  and  some  disad- 
vantages in  this  continuity  of  service  of  the  medical  staff.  The  patient  in  whose 
welfare  the  hospital  is  deeply  interested  obtains  better  treatment,  a  greater  amount 
of  consideration,  if  a  physician  who  has  studied  his  case  from  the  beginning  can 
be  allowed  to  treat  him  until  the  end.  To  that  extent  the  hospital  benefits.  The 
technic  of  the  institution,  the  methods  to  be  employed  by  the  interns  and  nurses, 
will  have  a  greater  permanence,  and  the  discipline  will  be  good  or  lax,  in  propor- 
tion as  the  service  of  the  medical  attendance  is  permanent  or  frequently  changed. 

Again,  a  great  deal  of  apparatus  and  many  instruments  are  employed  in  the 
institution,  each  physician  having  certain  notions  of  his  own  as  to  their  use.  If 
there  are  few  men  on  continuous  service  in  the  institution,  the  changes  in  appara- 
tus, the  demands  for  new  apparatus  and  new  instruments,  will  not  be  great,  and, 
in  proportion  as  the  number  of  men  on  service  during  the  year  increases,  so  will 
the  demands  for  new  things,  and  if  the  hospital  is  liberal,  and  if  the  rotation  of 
service  is  frequent,  it  can  well  come  to  pass  that  the  institution  will  find  itself 
burdened  with  the  expense  of  these  new  things,  and  top-heaviness  in  the  use  of 
a  great  variety  of  instruments  to  perform  the  same  service. 

The  board  of  directors  being  a  financial  body,  charged  with  the  physical  admin- 
istration of  the  institution,  and  constantly  looking  for  funds  with  which  to  conduct 
it,  and  being  in  a  measure  dependent  on  a  large  number  of  people  through  whom  to 
secure  these  funds,  will  be  interested  in  having  the  greatest  possible  number  of 
physicians  devoted  to  the  fortunes  of  the  institution,  anil  hence  will  lean  toward 
the  employment  of  a  large  medical  staff.  Sometimes  the  board,  anxious  to  secure 
the  co-operation,  financial,  social,  and  professional,  of  a  large  number  of  men,  will 


270  OPERATION   OF   THE    HOSPITAL 

look  about  for  reasons,  additional  to  the  real  ones,  which  may  be  used  as  argument 
in  favor  of  their  wishes,  and  occasionally  the  members  of  the  medical  staff  will 
supply  these  good  arguments,  not  from  any  wish  to  do  so,  nor  from  any  want  of 
interest,  but  from  lack  of  competition.  If  one  or  two  medical  men  are  kept  on 
continual  service  in  the  medical  department  year  in  and  year  out,  and  throughout 
the  year,  it  is  only  human  that  after  a  while  they  will  become  rather  careless,  slovenly 
in  their  work,  prone  to  throw  a  good  many  things  on  the  interns,  and,  "so  master 
so  man,"  the  interns  and  nurses  on  their  part  will  be  likely  to  become  negligent  and 
careless.  When  such  a  time  comes  the  institution  will  have  set  upon  a  period  of 
stagnation,  and  there  is  only  one  course  to  be  pursued  for  a  radical  cure,  that  is, 
the  appointment  of  additional  members  of  the  staff,  and  the  division  of  the  service 
by  periods  of  time  with  the  men  who  are  already  there.  This  course  will  set  up  a 
brisk  competition.  Each  set  of  visiting  men,  as  they  come  into  service,  will  be 
put  on  their  mettle.  They  will  be  obliged  to  do  their  best,  with  a  snappiness  and 
efficiency  that  will  show  up  well  in  comparison  with  their  fellows,  and,  in  the  end, 
such  a  course  will  bring  a  very  much  better  grade  of  work  to  the  patients  and  a 
higher  order  of  scientific  care. 

If  the  appointments  to  the  staff  are  so  arranged  that  all  of  the  men  can  be  on 
service  all  the  time,  it  must  be  kept  in  mind  that  no  emergency  must  arise  that  will 
not  bring  the  promptest  attendance  of  some  staff  member. 

The  skin  diseases  in  the  hospital,  for  instance,  may  be  rare,  and  the  attend- 
ance of  the  member  of  that  service  may  be  very  infrequently  required,  but  occasion- 
ally that  member  will  be  out  of  the  city  or  incapacitated,  for  some  reason,  when  he 
is  most  urgently  needed.  To  avoid  such  a  contingency  there  ought  to  be  for  each 
service  at  least  enough  men  so  that  one  or  the  other  can  always  be  on  call.  It  is 
an  embarrassing  thing  for  a  hospital  to  have  to  send  out  for  some  man  not  a  member 
of  the  staff,  who  has  perhaps  been  refused  membership,  because  the  attending 
physician  cannot  be  reached. 

Divisions  of  Service. — A  divided  authority  can  never  achieve  the  best  order  of 
service  in  any  direction.  In  any  branch  of  human  endeavor  a  general  is  left  free 
to  direct  the  activities  of  his  army.  The  captain  of  a  ship  is  given  despotic  power. 
This  principle  ought  to  prevail  in  the  medical  service  of  the  modern  hospital.  It 
will  not  be  always  in  the  interest  of  all  the  members  of  the  staff,  but  it  will  certainly  be 
in  the  interest  of  the  hospital,  and  the  chief  factor  we  must  consider — the  patient. 

This  idea  has  been  growing  on  the  hospital  world  for  several  years,  and  some 
of  the  best  institutions  of  the  country  are  already  pretty  well  forward  with  details 
of  arrangement,  looking  to  an  undivided  authority  in  all  their  medical  services. 
The  Massachusetts  General  Hospital  began  with  the  surgical  service,  and  at  date 
of  publication  of  this  work  had  extended  the  idea  to  its  other  primary  services, 
including  medicine. 

The  University  of  Minnesota  is  rather  unique  in  this  respect.  Possessed  with 
practically  unlimited  money  to  carry  out  high  ideals,  this  university  and  its  hospital 
have  developed  a  detail  of  arrangement  that  borders  on  the  ideal.  There  is  one 
single  authority  in  medicine,  another  in  surgery,  and  so  on  through  the  branches. 
Each  one  of  these  heads  has  under  him  two,  or  in  some  cases  three,  associates,  and 
these  associates  have  each  two  or  three  assistants,  and  these,  in  their  turn,  are 
assisted  by  the  senior  students  in  the  university  in  the  working  up  of  the  cases  in 
the  hospital. 

As  Dr.  Washburn  of  the  Massachusetts  General  Hospital  said  most  aptly  in 
a  bronchure,  which  he  published  at  the  time  the  surgical  services  of  that  institu- 
tion were  rearranged  under  this  plan: 


THK    MEDICAL  STAFF  271 

"The  position  of  chief-of-service,  whether  medical  or  surgical,  thus  becomes 
one  of  the  greatest  importance.  It  is  a  position  to  be  filled  by  a  man  of  singular  capa- 
bilities, not  necessarily  an  older  man,  a  great  surgeon,  an  eminent  physician  or 
brilliant  investigator,  but  a  man  who  combines  the  rare  qualities  of  tact,  generosity, 
judgment,  breadth,  executive  ability,  and  the  capacity  of  discerning  and  bringing 
out  the  best  in  other  men.  He  should  be  a  man  desirous  not  to  develop  his  service 
for  himself  or  his  own  reputation,  but  to  stimulate  the  highest  possible  develop- 
ment of  the  individuals  who  compose  it.  He  should  be  an  instigator  and  director 
of  investigation  and  progress.  Such  men  are  hard  to  find.  Upon  their  judicious 
selection  will  depend  the  success  of  the  present  project." 

This  single  authority  in  the  direction  of  scientific  services  of  the  hospital  has 
an  infinite  number  of  advantages,  and  its  only  disadvantage  worth  considering  is 
the  personal  equation — the  displacement  of  those  men  who  are  not  chosen  as  the 
chief — but  it  seems  hardly  fair  to  ask  an  institution  to  set  aside  an  admirable 
arrangement  in  behalf  of  its  management  and  its  patients  to  serve  the  interests  of 
individuals. 

Relations  Between  the  Departments. — There  is  another  phase  in  the  divisions 
of  service  in  a  general  hospital  that  ought  to  be  discussed  at  least  briefly.  The 
field  of  medicine  is  so  vast  in  this  advanced  day  that  many  specialties  have  arisen, 
and  in  a  general  hospital  these  specialties  are  assuming  an  aggressive  status,  and 
their  devotees  are  demanding  service  in  the  charity  wards  for  themselves.  How- 
ever much  we  may  favor  specialties,  the  fact  should  never  be  overlooked  that  all 
these  specialties  ultimately  must  submerge  themselves  into  one  of  four  or  five 
fundamental  departments.  For  instance,  if  we  take  surgery  in  the  broad  sense, 
we  cannot  afford  to  recognize  as  on  the  same  plane  with  it  such  special  branches 
as  genito-urinary  surgery,  brain  surgery,  orthopedic  surgery,  the  nose  and  throat, 
the  eyes,  dental  surgery,  and  so  on  ad  infinitum.  In  the  field  of  internal  medicine 
we  would  find  ourselves  in  a  maze  of  complexities  if  we  were  to  recognize  as  co- 
ordinate departments  such  specialties  as  the  throat  and  chest,  the  stomach,  the 
skin.  There  has  arisen  even  the  specialist  in  tuberculosis.  The  classic  quarrel 
between  the  internal  medicine  man  and  the  neurologist  concerning  the  cause, 
pathology,  and  treatment  of  hundreds  of  diseases  is  something  even  the  medical 
faculty  itself  avoids. 

If  then,  in  a  general  hospital,  we  designate  as  departments  medicine,  surgery, 
pediatrics,  and  obstetrics,  we  will  come  nearer  hitting  the  mark  than  by  any  longer 
division.  Perhaps  gynecology  might  be  added  to  this  list,  not  because  it  is  a  funda- 
mental department,  but  because  the  surgery  of  women  has  attained  so  large  a 
growth,  occupies  so  special  a  field,  and  requires  such  special  operative  training  that 
it  must  be  recognized  as  having  a  distinct  entity.  In  some  hospitals  the  practice 
is,  and  it  would  seem  properly  so,  to  have  every  case  admitted  to  one  or  the  other 
of  these  primary  departments  and  assigned  to  the  men  on  service  there.  If,  for 
instance,  it  is  a  surgical  case  that  may  subsequently  require  a  surgical  operation 
on  the  nose  or  throat,  then  the  general  surgeon  will  transfer  the  case  to  that  specialty, 
or,  if  it  is  a  case  of  inherited  deformity,  the  case  will  naturally  be  transferred  to  the 
orthopedist;  if  a  case  assigned  to  the  medical  service  develops  upon  examination  a 
neurologic  aspect,  then  the  medical  service  man  will  naturally  transfer  it  to  the 
specialist  in  that  department.  But  those  who  have  tried  to  differentiate  these 
cases  in  the  admission  room  will  understand  that  the  attempt  is  almost  fore- 
doomed to  failure. 

There  must  be  one  fundamental,  underlying  principle  in  the  management  of 
the  medical  staff  in  any  hospital  if  there  is  to  In-  harmony  anil  co-operation,  ami  that 


272  OPERATION   OF   THE    HOSPITAL 

is,  that  administration  must  be  accomplished  under  definite  and  fixed  policies,  and 
that  the  members  of  the  medical  staff  must  live  and  act  under  those  precepts,  and 
that  no  member  of  the  medical  staff  shall  have  power  to  give  any  orders  whatever, 
excepting  those  that  directly  appertain  to  the  care  of  his  individual  patient.  The 
moment  one  medical  man  can  give  an  order  concerning  the  transfer  or  removal 
of  a  patient  from  one  service  or  one  part  of  the  house  to  another  affecting  the 
patient  of  another  physician,  there  will  come  friction  and  disagreement  between  the 
individual  staff  members,  and  a  lack  of  harmony  to  mar  the  smooth  operation  of 
the  institution.  The  best  method  of  securing  co-operative  work  of  a  high  order  is 
to  have  the  members  of  the  services  enact  rules  for  the  government  of  their  several 
departments.  For  instance,  if  there  are  four  members  of  the  surgical  staff,  it  would 
be  in  order  to  have  them  formulate  what  they  consider  to  be  proper  rules  for  the 
surgical  work  of  the  hospital,  including  the  technic  of  the  operating-rooms,  technic 
of  the  minor  operations,  such  as  venesection,  injection  of  abdominal,  subcutaneous, 
and  venous  salines,  and  even  still  more  minor  operative  procedures,  like  catheteriza- 
tion, the  introduction  of  the  stomach-tube,  and  the  giving  of  high  rectals.  All  these 
things  are  subject  to  a  technic,  and  the  house  physicians  and  nurses  should  be  taught 
this  technic  uniformly  and  without  any  alternative.  No  physician,  staff  member  or 
otherwise,  should  be  allowed  to  disturb  it. 

When  such  a  code  of  rules  has  been  formulated  by  the  members  of  a  service 
staff,  it  should  be  the  duty  of  the  administrator  of  the  hospital  to  go  over  them  with 
the  medical  men,  pass  on  them  from  his  own  standpoint  of  administration,  and 
veto  any  part  of  them  likely  to  bring  disaster  or  inefficiency  or  friction  anywhere. 
Some  of  these  rules  will  be  in  reality  fundamental  policies,  in  so  far  as  they  affect  the 
conduct  of  the  staff  members  themselves,  and  will  be  covered  in  that  peculiarly 
elastic  thing  known  as  the  medical  code  of  ethics,  or  in  that  other  and  more  common 
form  of  ethics  called  courtesy,  or,  sometimes,  the  Golden  Rule.  These  rules  may 
be  so  wide-reaching  over  all  the  departments  that  we  can  better  apply  them  under 
other  headings,  such  as  rules  of  technic,  rules  for  interns,  rules  for  nurses,  and  the 
like.  There  are  three  departments  where  special  rules  of  this  character  will  not  fit 
the  hospital  in  general — surgery,  pediatrics,  and  obstetrics — and  under  proper  head- 
ings elsewhere  we  have  incorporated  these,  and  out  of  these  any  one  may  build  a  set 
of  rules  for  almost  any  part  of  the  institution  and  to  cover  any  special  conditions. 

The  Consulting  Staff. — In  most  large  general  hospitals  and  in  many  small 
ones  there  are  a  few  medical  men  who  have  passed  the  age  of  their  best  activity, 
who  have  served  the  institution  or  the  community  well  in  their  professional  capacity, 
and  on  whom  it  is  desirous  to  confer  the  highest  honors  which  the  institution  has  to 
offer.  If  these  men  are  kept  on  the  service  staff  they  stand  in  the  way  of  progress 
in  the  institution.  After  a  certain  age  men  do  not  readily  adopt  new  ways,  and  do 
not  take  readily  to  advances  in  medicine  and  surgery.  Any  institution,  therefore, 
in  which  the  scientific  work  is  dominated  by  these  men  must  fall  behind.  It  is  a 
wise  thing  in  such  cases  to  create  what  may  be  called  a  "consulting  staff,"  on 
which  the  older  men  are  given  places  as  posts  of  honor.  It  is  the  case  of  "old  men 
for  wisdom  and  young  men  for  war."  These  positions  are  not  merely  emeritus  in 
the  sense  used  by  medical  schools  or  educational  institutions;  they  are  oftentimes 
of  the  very  highest  order  of  good  to  the  hospital,  and  many  times  profitable  to  the 
incumbents,  because  these  men  are  set  upon  a  pedestal,  so  to  speak,  and  often  called 
by  the  younger  men  in  consultation  in  the  service  cases  in  the  hospital.  Thus 
others  likewise  learn  to  lean  on  their  judgment,  and  oftentimes  men  who  have  never 
had  a  large  consultation  practice  before  find  themselves  more  advantageously 
situated  in  this  regard  than  they  had  ever  hoped  to  be.     The  institution,  it  goes 


THK    MEDICAL    STAFF  273 

without  saying,  benefits  by  the  change  because  it  enlists  at  once  the  energies  and 
activities  of  younger  men. 

Automatic  Retirement  for  Age. — In  some  ably  conducted  hospitals  there  is  a 
rule  by  which  members  of  the  active  or  service  staff  are  retired  automatically  at  a 
prescribed  age,  precisely  in  the  manner  practised  in  the  United  States  Army  and 
Navy.  It  is  never  very  gracious  to  emphasize  the  old  age  of  those  we  respect,  and 
when,  coupled  with  an  implication  that  the  revered  person  is  past  his  usefulness,  it 
reaches  the  acme  of  cruelty.  How  much  better,  therefore,  to  formulate  a  rule  for 
general  application,  to  work  automatically  without  personal  reference.  The  end 
is  the  same;  the  harshness  of  the  act  is  somewhat  tempered  when  we  allow  one 
whom  the  institution  has  delighted  to  honor  to  step  gently  aside  instead  of  forcing 
him  out.  Every  one  else  knows  that  a  man  is  old  before  he  himself  realizes  it,  and 
too  often  he  will  persist  in  the  performance  of  a  fancied  duty,  even  when  all  the 
rest  of  us  know  that  his  service  is  without  value  and  oftentimes  actually  harmful. 

The  Adjunct  Staff. — Now,  having  selected  the  heads  of  the  several  departments, 
and  removed  as  gracefully  as  possible  the  dead  timber,  are  we  to  allow  the  busy 
senior  men  to  do  all  the  work,  and  determine  all  the  scientific  activities  in  their 
several  departments?  It  would  seem  not.  First,  they  are  too  busy,  and  have  too 
little  time  at  the  disposal  of  the  institution;  next,  they  have  in  many  cases  outworn 
the  ambitions  of  their  youth,  no  longer  need  the  peculiar  form  of  recognition  which 
comes  from  contributions  to  the  literature  of  their  profession,  from  their  attendance 
on  medical  societies,  from  the  institution  of  new  practices,  and  the  invasion  and 
exploitation  of  new  fields.  In  order,  then,  to  secure  the  greatest  possible  amount  of 
scientific  work  that  requires  time  and  ingenuity  there  must  be  certain  young  men 
attached  to  the  staff — coadjutors,  adjuncts,  or  auxiliary  men — who  have  their 
careers  before  them,  and  need  only  the  opportunity,  and  possibly  a  certain  amount 
of  direction  at  the  hands  of  the  older  men,  to  obtain  results  which  will  redound  not 
only  to  their  own  success,  but  that  of  the  institution  as  well.  Of  such  there 
should  be  a  sufficient  number  so  that  they  can  work  up  and  exhaust  the  ma- 
terial in  the  shape  of  patients  in  the  institution.  If  their  labors  are  directed  in 
right  channels,  and  along  lines  that  will  be  competitive  and  stimulating,  and  espe- 
cially if  their  efforts  are  aided  and  supplemented  by  the  directors  of  the  laboratory, 
pathologists,  bacteriologists,  and  physiologic  chemists,  they  will  turn  out  "Arbeits" 
which  will  meet  almost  immediate  recognition  of  every  interest  concerned. 

Relations  of  the  Medical  Staff  to  the  Superintendent  and  the 
Board  of  Directors 

It  should  always  be  understood  that  the  superintendent  of  the  institution  is 
the  executive  officer  of  the  board  of  directors.  He  is  not  a  member  of  the  medical 
staff,  and  his  functions  follow  precisely  along  the  lines  of  the  activities  of  the 
board  of  directors.  Their  privileges  are  his,  their  duties  are  his,  and  in  the  absence 
of  the  board  he  is  their  representative. 

Leaving  out  of  the  question  the  terms  of  employment,  the  medical  staff  is  an 
operating  department  of  the  institution,  and  its  members  must  always  be  con- 
sidered employees  under  the  board  of  directors,  no  matter  what  the  terms  of  contract, 
the  limitations  of  the  agreement,  or  the  personnel  of  the  medical  men  employed. 
The  argument  is  that  the  board  of  directors,  charged  with  the  duty  of  taking  care 
of  patients  in  an  institution,  has  made  arrangements  with  certain  medical  men  to 
perform  certain  duties  for  a  certain  consideration,  and,  where  a  definite  term  of 
appointment  is  named  in  the  creation  of  the  medical  staff,  this  term  of  employment 

18 


274  OPERATION    OF   THE    HOSPITAL 

may  be  considered  a  time  contract  made  by  the  board  of  directors  with  an  employee. 
To  be  sure,  there  is  usually  no  money  consideration  in  this  contract,  and,  generally 
speaking,  the  terms  of  employment  are  about  as  follows: 

The  board  of  directors,  party  of  the  first  part,  employs  Dr.  Blank,  party  of  the 
second  part,  to  treat  the  patients  in  the  institution,  and  to  do  whatever  work  is 
necessary  to  that  end,  the  consideration  being  that  the  doctor  has  been  given  an 
appointment  that  has  brought  with  it  high  prestige,  much  honor,  a  position  in  his 
profession  that  will  bring  him  a  larger  share  of  public  patronage  than  he  could  other- 
wise have  obtained,  and  a  much  wider  range  of  experience  than  he  could  have  had 
if  he  had  not  been  connected  with  the  institution.  We  have  in  this  sort  of  an  agree- 
ment the  actual  employment  of  the  doctor  and  the  consideration  he  is  to  receive. 
Carrying  this  commercial  figure  a  step  farther,  we  have  in  the  superintendent  of  the 
institution  the  general  manager  of  the  corporation,  through  whom  all  policies  of 
the  board  of  directors  are  executed  and  through  whom  all  orders  issue,  so  that  natu- 
rally it  transpires  that  the  members  of  the  medical  staff  must  transact  their  business 
with  him,  and  more  or  less  under  his  jurisdiction  and  direction. 

The  medical  staff  ought  to  be  able  to  look  to  the  superintendent  for  the  prompt 
and  efficient  transaction  of  whatever  business  may  be  required,  and,  if  he  is  fully 
awake  to  his  exact  status,  he  should  be  of  an  immense  amount  of  help  to  the  medi- 
cal staff  and  never  a  hindrance  in  their  work. 

It  may  be  seriously  doubted  if  there  should  be  written  or  printed  rules  for  the 
government  of  the  medical  staff  in  an  institution.  If  there  are  reasonable,  rigid 
rules  for  the  house  staff,  for  the  nurses,  precise  regulations  covering  the  status  of 
patients  in  the  institution,  and  a  fairly  detailed  printed  technic  for  the  operation  of 
the  various  departments,  instigated  by  the  medical  men  in  those  departments,  the 
question  of  rules  governing  the  conduct  of  the  visiting  staff  will  be  a  negligible  one. 
It  will  be  found  easy  and  pleasant,  by  reversing  the  position  of  members  of  the 
medical  staff,  and  by  making  them  a  part  of  the  administrative  force  of  the  insti- 
tution, each  member  with  his  own  responsibility,  to  see  that  all  rules  of  the  insti- 
tution are  being  carried  out.  In  this  way  the  members  of  the  medical  staff  are 
made  the  rule-making  power,  and  a  part  of  the  rule-enforcing  machinery,  rather 
than  the  objects  of  that  machinery.  For  instance,  let  us  say  there  is  a  rule  providing 
that  the  junior  intern  is  to  write  the  history  of  his  cases  within  twelve  hours  after 
the  admission  of  the  patient;  it  will  not  be  obeyed  unless  the  attending  physician 
on  that  service  demands  its  enforcement  as  a  part  of  the  administration. 

Relation  of  the  Medical  Staff  to  the  House  Staff 

The  policy  of  making  the  medical  staff  a  part  of  the  administrative  force  of  the 
institution  brings  us  to  the  relationship  between  the  visiting,  or  attending  staff,  and 
the  house  staff  of  the  institution.  Stated  bluntly,  it  is  that  of  master  workman  and 
apprentice. 

The  visiting  staff  does  not  appoint  the  house  staff,  does  not  prescribe  the  rules 
for  the  government  of  the  house  staff,  and  the  two  bodies  are  present  wholly  as 
fellow  employees  under  the  board  of  directors. 

Generally,  the  members  of  the  house  staff  are  not  paid  in  money  for  their  ser- 
vice; the  board  of  directors  rather  undertaking  to  give  these  young  men  a  certain 
experience  in  their  profession  in  consideration  of  their  labors  in  the  care  of  patients; 
and,  tacitly,  it  is  understood  that  acting  for  the  board  of  directors  in  this  special 
undertaking  the  members  of  the  medical  staff  are  committed  to  the  duty  of  instruct- 
ing these  young  men  in  the  performance  of  their  professional  duties. 


THE    MEDICAL    STAFF  275 

The  attending  physician  must,  therefore,  see  that  these  young  men  carry  out 
orders  promptly,  efficiently,  and  conscientiously;  and,  in  the  event  of  their  failing 
to  obey  their  superiors  in  this  way,  the  attending  physician  must  report  their 
dereliction  to  the  executive  officer  of  the  institution,  in  order  that  the  proper  dis- 
cipline lie  maintained. 

Let  it  be  understood  that  these  young  men  are  almost  as  unfamiliar  with  their 
duties  of  citizenship  as  they  are  with  the  practice  of  their  profession.  They  have 
not  yet  learned  a  correct  bearing  toward  patients,  toward  nurses,  and  toward  the 
public,  and  the  staff  member  has  not  performed  his  whole  duty  by  his  apprentice 
unless  the  lessons  that  he  teaches  go  beyond  mere  medical  service,  and  enter  upon 
the  domain  of  ethics  in  all  its  branches. 

Egotism  and  self-importance  are  the  legacies  of  youth,  and  these  breed  impatience 
of  counsel,  a  disposition  to  override  authority,  heedlessness  of  advice,  and  some- 
times bad  temper  and  impatient  personal  conduct.  It  would  seem  to  be  one  of  the 
self-appointed  tasks  of  the  attending  physician  in  an  institution  to  help  these  young 
men  overcome  these  inherent  weaknesses.  Just  how  this  task  shall  be  performed 
must  he  left  to  the  individual  member  of  the  medical  staff  and  of  the  house  staff — 
sometimes  by  good  advice,  calm  counsel,  sometimes  by  proper,  dignified  rebuke, 
which  we  may  be  pardoned  for  calling  a  "dressing  down,"  but  every  "dressing  down" 
should  carry  its  permanent  lesson. 

Medical  schools  of  the  day,  be  they  efficient  or  inefficient,  stop  short  of  teach- 
ing students  the  details  of  their  profession,  such  as  the  bedside  care  of  patients, 
whether  it  be  the  physical  handling  of  the  patient,  scientific  physical  diagnosis, 
clinical  pathology,  or  what  not,  and  only  too  commonly  the  visiting  staff  expects 
these  young  men  to  come  from  a  school  desk  into  an  immediately  efficient  hospital 
service.  They  have  in  their  minds  merely  some  vaguely  understood  theories  of 
medical  science,  fragmentary  bits  of  theoretic  knowledge,  and  their  very  presence 
in  the  hospital  as  interns  is  an  acknowledgment  of  their  inexperience  and  their 
desire  to  learn;  therefore,  members  of  the  visiting  staff  ought  to  be  patient  and 
painstaking  as  teachers. 

It  is  a  fact,  however,  that  many  of  the  schools,  and  some  of  the  very  best,  are 
turning  out  young  men  and  women  who  are  not  only  not  at  all  fitted  for  their  pro- 
fession, but  who  can  never  be  made  so.  It  is  the  duty  of  the  medical  staff  members 
to  detect  this  unfitness  in  its  incipiency,  and  to  insist  upon  the  withdrawal  of  the 
incompetent  from  the  position  of  responsibility  in  the  institution,  even  if  they 
are  not  able  to  effect  his  withdrawal  from  the  profession  itself. 

Relations  of  the  Medical  Staff  to  the  Nursinc;  Corps. 

What  has  been  said  above  can  almost  be  duplicated  in  this  place.  Unfortunately, 
a  v;ist  majority  of  the  young  women  who  apply  for  admission  to  training-school.-,  are 
undereducated,  both  in  book  learning  and  in  worldly  experience.  Most  of  these 
young  women  come  from  the  rural  districts;  they  have  been  reared  almost  within 
touch  of  the  mother's  apron  strings;  they  have  never  rubbed  elbows  with  the  world 
or  mixed  with  people;  therefore  are  not  only  ignorant,  in  the  broader  sense,  but  are 
likewise  without  rules  of  personal  conduct.  In  other  words,  they  are  little  more 
than  children.  Nurses  come  into  the  training-school  from  country  homes,  with  their 
canvas  bags  in  their  hands,  who  could  not  give  an  intelligent  answer  to  the  simplesl 
question  because  of  their  embarrassment;  some  of  them  are  afraid  of  the  elevator; 

some  are  afraid  to  sleep  alone  in  their  rooms.      Imagine,  then,  this  sort  of  girl  set 
to  work  upon  a  writhing,  bloody  patient,  and  wonder,  if  you  need,  why  she  does 


276  OPERATION    OF   THE    HOSPITAL 

not  make  good!  We  are  all  familiar  with  the  old  story  of  the  nurse  who  was  placed 
at  the  patient's  bedside  and  told  to  watch  for  hemorrhage,  and  who  watched  for 
hemorrhage  until  the  patient  had  bled  to  death,  without  knowing  enough  to  call  for 
help.  We  have  seen  this  same  girl,  and  watched  her  week  after  week,  month  after 
month,  year  after  year,  and  have  seen  her  unfold  and  develop,  and  have  seen  her 
become  veritably  a  nursing  machine  under  the  guidance  of  efficient,  careful  teach- 
ers; we  have  seen  this  same  sort  of  girl  devoted  to  the  point  of  utter  unselfishness; 
we  have  seen  her  step  to  her  duty  amid  loathesome  infections  without  the  slightest 
regard  for  self,  and  we  have  been  overjoyed  at  the  development  of  character  and 
efficiency  in  these  unlettered,  unlearned,  ignorant  country  girls,  and  have  wondered 
if,  after  all,  they  were  not  the  stuff  of  which  to  make  trained  nurses. 

And  we  have  seen  that  other  girl,  educated  at  finishing  schools,  reared  in  the  lap 
of  luxury,  kissed  always  by  a  kind  fortune,  bathed  in  the  sunshine  of  prosperity; 
have  seen  her  forsake  her  automobile,  her  beaux,  her  pretty  clothes  and  her  jewelry, 
and  don  the  nurse's  garb,  and  succeed  in  every  call  of  her  duty;  and  we  have  won- 
dered whether  this  was  not  the  stuff  of  which  trained  nurses  are  made. 

So  it  seems  the  girl  from  the  humble  home  in  the  country,  and  the  girl  from  the 
palace  in  town,  can  be  molded  and  developed  to  do  her  duty  as  a  trained  nurse, 
to  give  efficient,  prompt,  conscientious  care  to  the  sick,  and  we  have  conceived, 
after  all  these  experiences,  a  firm  conviction  that  the  trained  nurse  is  the  girl  of 
her  training,  and  that  as  her  training  has  been  so  will  she  be  as  a  trained  nurse. 

And  thus  we  come  to  the  relationship  of  the  medical  staff  to  the  trained  nurse, 
and  the  part  the  medical  man  must  play  in  that  training.  Patience,  care,  the  tell- 
ing over  and  over  and  over  again  of  the  way  to  do  things,  the  showing  of  the  way, 
practical  illustration,  bedside  help — these  would  seem  to  promise  more  in  the  field 
of  education  of  nurses  than  a  rigid  discipline,  fault-finding  censure  for  mistakes, 
holding  of  the  reins  against  innocent  pleasures  and  pastimes.  If,  moreover,  the 
attending  physicians  in  the  institution  will  help  train  the  pupil  nurses  in  this 
way,  their  reward  will  come  when  these  same  nurses  are  graduated  and  sent  into 
the  homes  to  take  care  of  their  private  cases;  for  there  they  will  show  their  effi- 
ciency and  devotion,  or  they  will  show  the  want  of  training,  for  which  the  physician 
is  in  no  small  measure  responsible. 

The  Open-door  Policy 

Most  hospitals  of  the  present  time  receive  not  only  the  private  patients  of  the 
members  of  their  regular  medical  staffs,  but  also  those  of  outside  physicians  who 
have  no  connection  with  the  institution.  The  exceptions  to  this  rule  are  the 
large  charity  hospitals  in  which  no  private  patients  are  cared  for,  such  special  hos- 
pitals as  are  operated  by  corporations  in  the  interest  of  their  employees,  and  a  few 
private  institutions  owned  by  one  or  more  physicians.  There  are  hardly  any  pri- 
vate or  semipublic  hospitals  which  do  not  accept  the  patients  of  outside  physicians. 
These  hospitals  are  known  as  open-door  hospitals.  Many  features  of  the  open-door 
policy  are  subject  to  serious  criticism,  and  again  it  has  many  advantages. 

Most  physicians  living  in  communities  populous  enough  to  afford  more  than  one 
hospital  are  usually  connected  more  or  less  intimately  with  one  or  the  other,  and 
will  naturally  prefer  to  send  their  private  patients  there;  but  most  sick  people, 
classed  as  private  patients,  also  have  some  hospital  connection  or  are  attached  for 
one  reason  or  another  to  some  particular  institution.  Usually  when  a  private 
patient  desires  to  go  to  some  hospital  to  which  the  physician  is  not  attached  his 
wishes  will  be  respected,  and  he  will  be  taken  where  he  wishes  to  go.     It  may  not 


THE    MEDICAL    STAFF  277 

bo  always  wise  for  the  patient  to  choose  a  hospital  with  which  the  physician  is  not 
acquainted,  because  every  medical  man  can  get  a  better  service,  at  least  one  with 
which  he  is  more  familiar,  in  the  hospital  where  most  of  his  work  is  done. 

It  is  not  a  very  difficult  matter  for  the  management  of  one  institution  to  classify 
professionally  the  physicians  in  the  community  who  are  attached  to  some  other 
hospital,  to  ascertain  their  abilities,  shortcomings,  and  peculiarities;  but  there  are 
some  medical  men  who  do  not  belong  to  any  hospital,  and  who  wrander  about  from 
one  institution  to  another,  sometimes  from  an  unsatisfied  desire  to  secure  a  better 
hospital  service  for  their  patients,  sometimes  because  their  peculiarities  or  their 
mediocrity  has  rendered  them  personae  non  gratae  wherever  they  have  gone,  and 
they  have  not  been  made  welcome  and  content. 

This  open-door  hospital  policy  has  been  rather  a  free  and  easy  one  until  within 
recent  years,  but  it  has  now  risen,  or  is  rapidly  rising,  to  the  dignity  of  a  very  dis- 
tinct ethics,  and  the  more  responsible  and  progressive  institutions  are  facing  the 
necessity  of  enacting  some  very  radical  restrictions. 

In  most  hospitals  the  technical  training  of  interns  and  nurses,  and,  indeed, 
the  whole  hospital  entourage,  has  come  to  be  one  of  the  most  important  features 
of  the  institution  practice,  and,  if  there  is  to  be  a  regular  technical  routine  practice 
as  laid  down  by  the  responsible  medical  heads  of  the  several  departments,  no  out- 
sider may  come  and  lightly  set  these  well-established  practices  aside.  Whoever 
comes  into  a  hospital  to  which  he  is  not  attached  must  inevitably  do  his  work  under 
a  technic  with  which  he  is  not  familiar.  For  this  reason,  most  of  the  prominent 
surgeons,  and  more  especially  obstetricians,  whose  work  is  done  usually  under  exact- 
ing conditions,  refuse  to  operate  in  institutions  other  than  their  own.  The  time 
seems  to  be  very  rapidly  approaching  when  every  physician  will  have  to  be  definitely 
connected  with  some  one  institution  and  do  all  his  work  there;  and,  at  a  day  not 
far  distant,  no  institution  of  standing  and  responsibility  will  allow  a  member  of  its 
medical  staff  to  be  connected  with  any  other  institution.  This  will  mean  a  tre- 
mendous step  in  hospital  progress,  and  will  speak  immeasurably  for  the  advantage, 
not  only  of  the  physician  and  the  hospital,  but  for  the  patient's  best  good. 

Some  very  important  ethical  points  must  be  met  fairly  and  settled  equitably. 
In  the  first  place,  it  has  come  to  be  a  very  common  feeling  of  members  of  the  medi- 
cal profession  that  they  cannot  take  a  private  patient  to  a  hospital  not  their  own 
without  fear  of  his  being  taken  away  from  them  by  some  factor  in  the  hospital 
administration,  and  turned  over  bodily  to  a  member  of  the  medical  staff  of  the  insti- 
tution. The  interns  and  nurses  are  usually  implicated  in  this  habit  of  "case 
stealing"  in  some  hospitals.  It  should  be  a  well-recognized  rule  of  every  hospital, 
large  or  small,  that  no  physician  may  ever  have  his  patient  alienated  by  any  act 
on  the  part  of  the  hospital  administration  or  any  one  who  works  there. 

Dr.  Jones  sends  his  patient  to  a  hospital  with  which  he  has  no  connection,  and 
in  which  he  is  not  acquainted,  and  he  proposes  to  perform  a  surgical  operation  upon 
the  patient;  a  few  days'  time  will  be  necessary,  perhaps,  for  the  patient  to  1  le  properly 
prepared;  presently  a  nurse  or  intern  will  drop  some  light  remark  within  the 
patient's  hearing  that  Dr.  Smith's  patient,  a  Mrs.  So-and-So,  is  going  home  to-day; 
she  was  operated  upon  last  week  for  precisely  the  same  disease  that  Dr.  Jones' 
patient  has;  indeed,  it  is  truly  remarkable  how  many  of  these  cases  Dr.  Smith  has 
operated  upon  successfully  and  not  one  of  them  had  died. 

"How  about  Dr.  Jones?"  the  patient  in  bed  will  ask;  "isn't  he  a  got  id  surgeon?" 

"Oh,  I  wouldn't  for  the  world  say  anything  against  Dr.  Jones,"  the  nurse  will 
reply.  "He  is  probably  an  excellent  surgeon,  but  of  course  we  do  not  know  him, 
and  we  do  know  that  Dr.  Smith  has  had  hundreds  of  these  cases,"  and  the  nurse 


278  OPERATION    OF   THE    HOSPITAL 

will  probably  mention  any  number  of  cases  that  have  been  recently  in  the  hospital, 
and  have  been  operated  upon  for  this  same  disease  by  Dr.  Smith,  and  that  have 
recovered  in  almost  no  time  and  have  gone  home  permanently  cured. 

The  patient  will  probably  not  say  very  much  more  on  the  subject,  but  as  she 
lies  in  bed  in  the  dark  of  the  night,  thinking  about  the  hazards  of  the  operation  she 
is  about  to  undergo,  it  is  almost  a  moral  certainty  that  by  morning  she  has  concluded 
that  if  Dr.  Smith  has  been  so  eminently  successful  in  this  particular  line  of  work,  and 
that  if  Dr.  Jones  is  not  known  at  all  for  his  work  in  this  direction,  it  stands  to  reason 
that  she  ought  to  have  Dr.  Smith  do  the  operation  upon  her,  and  Dr.  Jones  will 
lose  the  case  and  Dr.  Smith  will  do  the  operation. 

Again,  members  of  medical  staffs  of  most  institutions  are  rather  inimic  to 
outside  physicians.  They  are  not  very  gracious  about  welcoming  them,  and  some- 
times go  so  far  as  to  render  their  work  difficult  and  their  positions  uncomfortable. 
Oftentimes  this  attitude  of  the  medical  staff  takes  on  the  dignity  of  an  actual  hospi- 
tal atmosphere  against  outsiders,  so  much  so  that  the  interns  and  nurses,  unless 
closely  watched,  will  give  as  little  service  and  as  poor  a  service  to  the  outsider  as 
they  dare.  Sometimes  there  is  a  show  of  reason  for  this  feeling  of  hostility  on 
the  part  of  the  interns  and  nurses;  most  of  these  young  people  are  trained  by  the 
members  of  the  medical  staff,  and  naturally  are  taught  that  the  technic  and  the 
routine  procedures  of  their  teachers  are  really  text-book  practices,  and  that  no  other 
technic  is  proper  or  legitimate.  The  encouragement  of  this  feeling  is  not  altogether 
wrong,  because  interns — and  more  especially  nurses — are  more  or  less  creatures 
of  habit  and  training,  and,  unless  instructed  that  there  is  only  one  right  way  to  do 
a  thing,  are  pretty  apt  to  think  that  almost  any  way  will  do;  hence  the  necessity  of 
a  distinct  technic.  It  follows,  therefore,  that  when  some  outside  physician  comes 
in  and  proposes  a  line  of  procedure  wholly  at  variance  with  what  these  young  people 
have  been  taught,  they  naturally  are  not  very  much  impressed  with  the  ability  and 
learning  of  the  outsider,  no  matter  how  he  may  measure  up  in  the  profession  at  large. 

Then,  very  often,  these  young  people,  especially  in  the  larger,  more  progressive 
institutions  in  the  centers  of  population,  are  pretty  good  judges  of  what  constitutes 
proper  technic  and  proper  procedure.  The  interns  in  these  institutions  are  from 
the  best  schools,  and  usually  the  best  men  from  those  schools.  Where  this  is  the 
case,  the  position  of  the  outside  medical  man  of  mediocrity  is  a  very  difficult  one. 

In  the  medical  departments  of  the  hospital,  and  in  those  other  sections  of  the 
institution  where  promptness  and  instant  action  are  not  quite  so  important,  it  does 
not  matter  quite  so  much  if  a  mediocre  or  poorly  informed  medical  man  has  a  pri- 
vate case  for  treatment,  because  it  will  not  take  the  administration  very  many  days 
to  learn  whether  the  doctor  is  giving  his  patient  adequate  attention.  But  in  the 
departments  of  surgery  and  obstetrics,  and  such  specialties  as  the  eye,  the  ear,  nose, 
and  throat,  where  a  single  act  or  an  instant's  delay  may  mean  success  or  failure, 
the  case  is  vastly  different.  It  would  seem  to  be  the  duty  of  the  hospital  administra- 
tor to  know  his  man  well,  or  for  some  member  of  the  staff  to  know  him,  before  an 
outside  physician  is  allowred  to  engage  the  operating-rooms  or  to  bring  an  operative 
patient  into  the  institution.  It  makes  very  little  difference  to  the  outside  layman 
whether  or  not  the  doctor  is  a  member  of  the  staff  so  long  as  he  is  permitted  to 
operate  in  the  institution;  and  the  public  generally  will  measure  the  class  of  work 
done  in  the  institution,  not  by  that  of  its  strongest  staff  member,  but  by  that  of  the 
weakest  outsider  allowed  to  operate  there. 

It  is  a  difficult  matter  to  open  just  a  crack  of  the  door  of  the  hospital  to  the  out- 
side physician,  or  to  open  it  to  the  physician  and  keep  it  closed  to  the  surgeon  or 
obstetrician;  but  the  time  seems  to  be  very  rapidly  approaching  when  this  will  have 


THK    MEDICAL   STAFF  279 

to  be  done.  Most  hospital  administrators  will  recall  instances  within  their  own  insti- 
tutions where  patients  have  selected  the  doctor  wholly  by  reason  of  the  fact  that 
he  was  reputed  to  be  a  regular  operator  in  that  hospital,  and  were  not  aware  that 
he  was  merely  there  as  an  outsider  when  he  chose  to  bring  a  private  patient.  They 
have  judged  the  doctor  by  the  institution,  and.no  institution  can  afford  even  pas- 
sively to  submit  and  to  allow  such  judgment  to  prevail;  assuming  all  this  time,  of 
course,  that  the  medical  staff  of  the  institution  is  composed  of  the  best  men  in  the 
community. 

In  the  establishment  of  the  open-door  policy  in  an  institution  some  very  definite 
rules  should  be  laid  down  for  the  conduct  of  outside  men  who  bring  their  patients 
there ;  rules  relating  largely  to  the  duties  of  the  administrator  of  the  hospital  under 
such  conditions.  If,  for  instance,  a  physician  brings  a  medical  case  to  the  hospital, 
and  persists  in  a  flagrantly  wrong  diagnosis  and  a  bad  course  of  treatment,  according 
to  the  standards  of  the  institution,  as  judged  by  the  laboratory  men  and  house 
physicians,  it  would  seem  to  be  the  immediate  duty  of  the  superintendent  of  the 
hospital  to  call  the  attention  of  the  physician  to  the  view-point  of  the  institution 
in  regard  to  the  conduct  of  his  case,  and  to  insist  upon  a  consultation  with  some 
physician  in  whom  the  institution  has  confidence.  The  superintendent  would 
naturally  allow  the  physician  a  wide  choice  of  consultants,  without  even  a  hint  that 
the  consultant  should  be  a  member  of  his  own  medical  staff,  because  that  would 
look  as  though  there  were  an  attempt  to  take  the  case  from  the  physician  who  had 
brought  it  there  in  the  interest  of  a  member  of  the  hospital  medical  staff. 

This  duty  is  a  most  delicate  one.  In  the  first  place,  who  is  competent  to  say 
that  the  case  has  been  mismanaged?  The  superintendent  himself  has  not  seen  it, 
and,  even  if  he  has,  he  is  not  in  active  practice,  and  is,  therefore,  not  competent, 
at  least  theoretically,  to  pass  upon  the  merits  of  a  case  open  to  discussion  in  the 
matter  of  diagnosis.  No  member  of  the  regular  staff  has  seen  it,  and  if  he  has,  he 
has  been  guilty  of  the  grossest  violation  of  the  very  fundamental  principle  of  pro- 
fessional ethics  in  visiting  and  examining  the  patient  of  another  physician  without 
his  consent,  and  in  no  case  could  the  superintendent  use  information  obtained  in 
that  way.  Is  it  a  house  physician  or  an  intern  who  has  brought  the  case  to  the 
attention  of  the  office?  Who  has  set  these  young  men  up  as  critics  of  their  elders? 
They  are  only  beginners  themselves.  Sometimes  reliable  information  can  come  by 
way  of  the  laboratory  of  pathology,  where  the  technical  findings  in  the  case  will 
be  so  contradictory  of  the  clinical  diagnosis  as  to  justify  complaint  on  the  part 
of  the  hospital  administration.  Sometimes  the  matter  may  be  delicately  brought 
up  in  some  such  way  as  occurred  not  long  since  in  a  large  hospital,  to  which  a 
patient  had  been  admitted  to  the  service  of  an  outside  physician  with  a  diagnosis 
of  appendicitis.  The  operating-room  had  been  ordered  for  an  emergency  operation. 
The  patient  was  admitted  at  two  o'clock  and  the  hour  for  operation  set  at  four. 
When  the  intern  approached  the  bedside  for  the  routine  history,  he  was  so  im- 
pressed with  the  condition  of  the  patient  that  he  at  once  reported  the  case  to  his 
senior,  and  together  they  made  a  clear  diagnosis  of  pneumonia,  with  manifesta- 
tions pointing  somewhat  toward  appendicitis. 

When  the  physician  arrived,  just  before  time  for  the  operation,  he  was  asked  to 
see  the  superintendent  before  going  upstairs,  and  the  following  very  brief  dialogue 
took  place: 

"Doctor,  I  am  obliged  to  inform  you  that  your  patient  seems  to  have  devel- 
oped a  pneumonia  since  you  saw  her,  ami  I  have  taken  the  liberty  to  cancel  your 
operation;  of  course,  I  knew  you  would  not  want  to  operate  on  a  patient  in  that 
condition." 


280  OPERATION    OF   THE   HOSPITAL 

"I  am  surprised  at  the  turn,"  replied  the  physician,  "but,  if  that  is  the  case,  of 
course  I  would  not  want  to  operate." 

As  a  matter  of  fact,  the  patient  had  a  well-developed  second  stage  of  pneu- 
monia at  the  time,  ran  a  typical  course,  and  got  well.  The  physician's  feelings  were 
respected,  his  patient  protected,  and  the  incident  closed  in  the  friendliest  way. 

If  the  patient  is  brought  by  an  outside  physician  to  one  of  the  operating  depart- 
ments of  the  hospital  there  should  be  well-defined  limitations  and  definite  rules  laid 
down  for  the  conduct  of  members  of  the  medical  profession,  whether  they  be  of  the 
medical  staff  or  not,  so  that  there  will  be  a  feeling  that  all  physicians  are  being  treated 
alike.  If  it  is  the  surgical  department,  the  rules  of  technic  and  asepsis  should  be 
pointed  out  to  the  newcomer,  and  he  should  be  courteously  informed  that  there  is 
no  departure  from  these  rules.  This  would  include  the  method  of  cleaning  up  for 
an  operation,  the  wearing  of  gloves,  and  the  asepsis  generally,  but  he  should  of 
course  be  allowed  the  widest  latitude  in  the  professional  treatment  of  his  patient. 
If  the  operator  is  not  well  known  as  a  surgeon,  he  should  have  the  services  of  the  best 
house  surgeons  or  senior  interns  to  assist  him,  and  if  they  are  capable  men,  and  if 
there  is  an  efficient  nursing  corps,  the  inexperienced  operator  will  not  be  likely  to 
go  very  far  wrong  before  his  assistants  ascertain  his  incapability,  and  give  him  a 
sufficient  amount  of  help,  courteously  offered,  to  bring  the  operation  to  a  successful 
issue. 

After  the  first  operation  the  hospital  administrator  will  have  no  difficulty  in 
securing  information  as  to  whether  or  not  the  operator  ought  to  be  invited  to  con- 
tinue surgery  in  the  institution,  and  if  not,  the  visitor  should  be  politely  informed 
that  his  discontinuance  would  be  appreciated. 

It  is  in  the  obstetric  department  of  the  institution  where  the  most  harm  can  be 
done  in  the  least  possible  time  by  an  inexperienced  man.  In  surgery  the  operator 
sets  out  to  perform  a  definite  operation  under  classical  rules,  well  understood  by  the 
house  staff,  and  any  departure  from  these  narrow  limitations  as  to  how  an  operation 
should  be  performed  will  be  recognized  almost  immediately,  and  the  attention  of 
the  operator  called  to  the  fact.  In  the  obstetric  department,  however,  the  case  is. 
vastly  different;  there  is  no  infallible  rule  when  forceps  should  be  applied  that  will 
fit  all  cases;  there  is  no  definite  instant  at  which  labor  should  be  immediately  induced 
that  can  be  universally  applied;  those  procedures  must  depend  so  much  on  the 
condition  of  the  child,  and  the  condition  of  the  mother,  and  an  infinite  number  of 
conditions  in  detail,  that  the  conduct  of  the  obstetrician  must  be  based  upon  a 
broad  knowledge  applied  to  the  particular  case  in  hand.  Poor  judgment,  or  ignor- 
ance, or  a  want  of  technical  skill,  may  destroy  mother  or  child,  or  both,  before  the 
operator  can  be  interfered  with.  And,  in  the  case  of  a  postpartum  hemorrhage, 
there  will  be  no  time  to  discuss  the  line  of  conduct  and  the  wisdom  of  a  particular 
procedure.  The  operator  will  have  to  act  instantly,  and  sometimes  radically,  and 
if  he  acts  wrongly  the  institution  will  suffer  for  his  wrongdoing.  So. that  in  this 
one  department,  at  least,  if  the  institution  is  to  become  famous  for  the  skill  and  dex- 
terity and  success  of  its  obstetric  service,  it  would  seem  almost  necessary  to  limit  the 
courtesies  of  the  institution  to  those  who  have  well-established  reputations  for  their 
ability  in  that  field. 

Relations  of  the  Hospital  to  the  Medical  School 

The  relationship  between  affiliated  hospitals  and  medical  schools  has  been 
very  far  from  satisfactory  in  the  past,  largely  due  to  the  differences  in  view-point 
between  hospital  administrators  and  the  faculties  and  trustees  of  the  medical  schools. 


THE    MEDICAL    STAFF  281 

Faculty  members  in  medical  schools  have  been,  and  still  are,  very  prone  to  feel 
that  the  teaching  end  of  the  combination  is  about  the  only  part  really  worth  while, 
and  that  the  hospital  is  an  after  consideration  and  should  be  merely  an  adjunct, 
and  consequently  under  the  absolute  direction  of  the  school  authorities. 

Unfortunately,  this  attitude  has  been  strengthened  and  given  countenance  by 
the  fact  that  the  hospitals,  as  a  class,  have  not  been  up  to  date,  and  have  not 
kept  in  step  with  the  march  of  medical  science;  and  the  college  professors  have  felt 
that  they  should  be  in  authority  to  an  extent,  at  least,  that  would  give  them  con- 
trol of  hospital  material  for  scientific  and  teaching  purposes,  to  the  end  that  they 
could  enforce  what  they  regarded  as  proper  hospital  practice. 

Very  many  of  the  college  professors,  too,  have  been  either  educated  abroad  or 
have  taken  postgraduate  courses  in  the  great  centers  of  Europe,  where  patients 
have  no  other  aspect  than  as  "clinical  material,"  without  very  much  regard  for  the 
life  or  health  of  that  material.  In  this  country  this  view-point  as  to  the  patient  is 
repugnant,  and  the  sympathies  and  sentiments  of  the  people  will  not  permit  the 
brutalizing  instinct  to  prevail  with  public  charges  as  its  object.  The  humanitarian 
view  is  dominant  in  this  country,  and  even  in  the  great  eleemosynary  institutions, 
supported  wholly  by  charity,  there  is  a  unanimous  demand  on  the  part  of  the 
public  that  the  inmates  shall  be  treated  with  something  like  recognition  of  the 
Golden  Rule,  and  it  goes  without  saying  that  private  hospitals,  and  those  supported 
in  a  measure  by  subscriptions,  demand  good  care  of  the  patient  first  and  the  abstract 
benefits  to  science  as  an  after  consideration. 

There  is  no  reason  why  the  two  factors  in  this  classical  controversy  cannot  be 
reconciled  under  terms  by  which  both  will  be  vastly  benefited.  In  the  first  place, 
the  schools  have  a  right  to  demand  of  the  hospital  the  scientific  treatment  of  dis- 
ease and  equipment  commensurate  with  that  purpose,  so  that  their  students  may  be 
taught  modern  medical  methods  at  the  bedsides  in  the  wards  of  the  institution. 
The  medical  profession,  as  expressed  in  the  school  faculties,  has  a  right  to  a  review 
of  its  scientific  work  for  the  benefit  of  humanity,  meaning  by  this  the  right  of  autop- 
sies when  there  is  any  scientific  point  at  issue.  Almost,  if  not  every  state  in  the 
American  Union,  prohibits  an  autopsy  without  the  express  consent  of  the  friends 
of  the  dead;  and  there  is  a  very  pervading  notion  in  the  public  mind,  which  expresses 
itself  also  in  boards  of  trustees  of  hospitals,  that  hospital  administrators  should  go 
to  the  extreme  in  forbidding  the  autopsy  as  a  sweeping  routine.  The  law  about 
autopsies  should  be  changed.  We  are  past  the  Dark  Ages,  when  the  mutilation  of 
the  dead  was  considered  a  sacrilege.  The  fact  is,  there  is  no  religion  dominant  in 
this  country  to-day  that  has  one  word  or  one  rule,  or  one  principle  in  its  creed, 
that  forbids  the  autopsy,  and  there  is  no  telling  what  untold  harm  is  being  done 
to  humanity  every  day  by  the  burial  of  professional  mistakes,  that,  if  properly  re- 
viewed, might  clear  up  and  make  curable  many  diseases  that  are  now  obscure  and 
incurable.  The  medical  faculties  are  right,  therefore,  in  demanding  a  better  co- 
operation and  a  greater  amount  of  complaisancy  on  the  part  of  the  hospital  in  regard 
to  postmortem  material. 

Then,  again,  in  these  days  of  higher  medical  education  and  more  practical  teach- 
ing, very  much  of  the  school  work  is  done  in  the  wards  of  the  hospital,  and  how  can 
this  teaching  be  done  unless  the  hospitals  themselves  are  doing  in  a  routine  way  the 
class  of  work  that  the  teachers  are  trying  to  impress  upon  their  students?  In  other 
words,  the  professor  of  medicine  has  been  lecturing  for  months,  say,  to  his  pupils 
upon  the  value  and  significance  of  urine  examinations,  blood-counts,  blood-press- 
ure, and  the  microscopic  and  chemic  analysis  of  secretions  and  excretions;  then 
he  takes  his  class  into  the  wards  of  the  hospital,  only  to  find  thai   the  records  of 


282  OPERATION    OF   THE    HOSPITAL 

the  institution  express  only  the  physical  examination  as  it  was  conducted  fifty 
years  ago — that  is,  examination  by  the  eye  and  ear  of  the  physician — his  splendid 
lectures  upon  the  scientific  aids  to  diagnosis  must  be  wholly  lost  upon  the  student 
in  such  an  instance  as  this,  and  the  professor  has  a  right  to  something  better. 

There  is  no  good  reason  why  there  should  be  a  controversy  between  the  hospital 
administration  and  the  teacher  in  the  school.  It  should  be  well  understood  by  both 
that  no  patient  need  be  subjected  to  a  clinic  examination  or  clinic  treatment  without 
his  consent,  whether  he  be  a  private  or  charity  patient.  Charity  patients  on  the 
wards  of  the  hospital  may  have  been  failures  in  their  financial  operations  of  life, 
but  most  of  them  usually  have  a  good  deal  of  canniness  or  common  sense,  and  it  is 
a  well-known  mental  attitude  of  these  people  that  they  want  the  highest  grade  of 
professional  care,  and,  as  a  rule,  they  are  pleased  when  the  "professor"  takes  them 
before  the  class  and  goes  over  them  carefully;  and  when  he  points  out  something  to 
the  members  of  the  class  that  seems  to  be  of  unusual  interest,  the  patient  has  a 
feeling  that  the  professor  is  getting  near  the  diagnosis,  and  that  this  must  be  speed- 
ily followed  by  a  cure.  It  is  common  knowledge  in  hospitals  everywhere  that 
patients  want  to  be  shown  before  the  classes,  and  that  they  go  back  to  their  wards 
and  talk  about  their  experiences  to  their  fellow-patients  with  much  pride  and 
satisfaction. 

There  is  a  vast  difference  between  showing  the  patient  before  the  class  and 
subjecting  that  patient  to  a  painful  or  wearying  examination,  and  the  humane 
professor  will  be  quite  as  anxious  not  to  tire  or  hurt  the  patient  as  the  hospital 
administrator  or  its  trustees. 

It  should  be  the  highest  ambition  of  the  trustees  of  the  hospital  to  have  their 
patients  given  the  best  possible  scientific  attention,  and  it  is  common  knowl- 
edge in  professional  circles  that  teachers  in  the  schools  spend  more  time  and  more 
patience  in  their  examinations  when  they  know  their  work  is  to  be  reviewed  before 
the  class  than  they  could  possibly  afford  for  mere  private  purposes;  and,  in  the 
long  run,  the  patients  in  the  hospitals,  where  there  is  teaching  and  where  the 
teachers  are  always  on  their  mettle,  will  get  better  care  than  is  the  case  in  private 
hospitals,  where  the  diagnosis  lies  solely  in  the  mind  of  the  attending  physician 
without  the  stimulus  of  outside  inspection. 

It  is  said  sometimes  that  the  professors  in  the  schools  who  hold  clinics  in  the 
hospitals  give  orders  for  patients  that  are  too  expensive  to  be  carried  out,  and  that 
inroads  are  thereby  made  on  hospital  finances  by  men  who  have  no  personal  interest 
in  the  conduct  of  the  institution  and  its  economies.  This  point  is  hardly  worthy 
of  notice.  There  are  no  professional  men'  in  the  great  schools  of  the  country  who 
are  not  reasonable  enough  to  understand  the  limitations  in  the  finances  of  the 
hospitals,  and  who  will  not  regulate  their  orders  accordingly. 

Taking  the  other  horn  of  the  dilemma — hospitals  that  cannot  afford  to  carry  out 
the  doctors'  orders — that  is,  the  orders  of  doctors  interested  solely  in  the  welfare 
of  the  patient  and  his  recovery — ought  to  close  their  doors,  or  else  limit  the  number 
of  patients  within  their  means.  We  may  go  a  step  further,  and  say  that  the  hospi- 
tal that  cannot  afford  the  necessary  apparatus  and  the  necessary  equipment  to  give 
all  of  the  modern  scientific  aids  to  the  physician,  to  the  end  that  he  may  make  his 
diagnosis  and  treat  his  patient  properly,  ought  also  to  go  out  of  existence,  and  give 
over  its  humanitarian  work  to  those  who  have  the  confidence  of  the  giving  public 
sufficiently  to  enable  them  to  attract  the  necessary  funds  for  their  purpose. 

There  are  some  affiliated  hospitals  and  schools  that  are  operated  under  one 
management  and  supported  out  of  a  common  fund ;  there  seems  no  reason  why  this 
fact  should  make  any  difference.     The  hospital  administrator,  if  he  be  a  medical 


THE    MEDICAL   STAFF  283 

man.  and  it  is  unlikely  that  any  other  will  be  placed  in  charge  of  an  institution  30 
intelligently  conducted  as  the  school  hospital  is  certain  to  be,  will  know  quite  ae 
well  as  the  faculty  member  whether  a  given  ease  is  in  condition  to  be  shown  in  a 
clinic,  and  his  should  he  the  final  decision  where  the  patients  of  the  institution  an' 
concerned.  There  are  certain  faculty  members  in  most  schools,  who  either  use 
little  judgment  in  this  regard  or  quite  systematically  sacrifice  the  interests  of  the 
patients  to  their  own  enthusiasm;  but  such  men  are  not  the  dominant  spirit  in  any 
of  the  great  schools,  and  they  can  and  should  be  controlled  and  their  activities 
should  be  suppressed. 

Then,  again,  questions  are  constantly  arising  as  to  just  what  service,  what  appa- 
ratus, and  what  equipment  shall  be  furnished  by  the  school  and  what  by  the  hospi- 
tal; this  seems  also  unnecessary  if  both  sides  are  disposed  to  be  fair-minded.  Of 
course,  if  either  the  school  or  hospital  has  plenty  of  money  and  the  other  is  strug- 
gling to  get  along,  the  rich  one  will  naturally  have  to  do  more  than  its  fair  share; 
but,  if  both  are  alike  in  this  particular,  why  would  it  not  be  an  equitable  adjust- 
ment for  the  hospital  to  furnish  everything  that  it  would  have  to  furnish  for  a  high 
order  of  scientific  care  of  patients  if  there  were  no  school,  and  for  the  school  to  do 
all  the  work  of  treating  the  patients  and  furnish  such  apparatus  as  applies  to  the 
actual  teaching  of  students,  and  which  is  of  no  particular  value  in  the  treatment  of 
patients.  For  instance,  blood-counters,  hemoglobinometers,  blood-pressure  ap- 
paratus, electric  apparatus,  such  as  x-ray  machines  and  batteries,  and  a  laboratory 
in  which  to  examine  urines;  blood  and  pathologic  tissues  are  needed  for  actual 
diagnosis  and  treatment  in  connection  with  the  patients,  and  the  hospital  should 
furnish  them.  If  more  microscopes  and  a  greater  number  of  these  other  things 
are  needed,  so  that  a  greater  number  of  students  may  have  the  use  of  them,  the 
school  should  furnish  them. 

A  great  many  hospital  administrators  and  boards  of  trustees  are  under  the 
impression  that  the  hospital  gives  more  than  it  gets  out  of  such  a  partnership; 
but  it  must  be  remembered  that  school  teachers  are  usually  the  best  men  in  the 
community,  and  that  they  give  the  best  of  their  time  and  their  talents  to  the  patients, 
not  wholly  with  an  eye  single  to  the  patients,  perhaps,  but  they  do  it,  and  so  the 
patients  get  a  service  vastly  superior  to  what  they  would  otherwise  receive,  and  the 
efficiency  of  the  hospital  and  the  good  it  does  are  increased  by  that  much.  Even 
the  same  men,  without  the  teaching  stimulus,  would  not  spend  half  the  time  or 
take  half  the  pains  with  their  work. 


HOUSE  MEDICAL  STAFF 

Duties  of  the  Modern  Intern 

Internship  in  the  modern  hospital  has  changed  very  radically  within  the  past 
few  years.  It  is  not  so  long  ago  that  the  hospital  intern  was  part  nurse,  part 
doctor,  and  very  much  of  a  menial.  He  was  required  to  do  dressings,  and  wait 
on  himself,  to  move  patients  in  bed,  to  give  enemas,  tub  typhoids,  give  hypodermic 
injections,  do  all  the  catheterizing  of  patients,  and  see  that  the  doctor's  orders 
were  carried  out;  in  some  hospitals,  in  order  to  fill  in  his  time,  he  was  expected  to 
clean  instruments  and  apparatus,  and  do  a  good  deal  of  work  that  is  now  confined 
to  the  hospital  orderly.  No  doubt  in  many  hospitals  this  general  routine  of  intern 
duty  still  prevails  to  a  certain  degree,  especially  in  small  hospitals,  and  in  this 
class  of  institutions  that  same  intern  will  be  charged  with  the  serious  care  of 
patients. 

In  the  modern  hospital  this  has  changed  to  a  great  extent,  and  the  character 
and  equipment  of  the  intern  has  changed.  Under  the  old  regime,  the  intern 
had  often  come  direct  from  the  plow,  with  little  or  no  education,  and  had  "read" 
medicine  for  two  short  terms  of  four  or  five  months  each,  and  he  was  expected  to  be 
equipped  to  practice  his  profession,  but  in  those  days  there  was  practically  no 
hospital  pathology,  almost  no  urine  examination,  no  blood  work  whatever,  and  no 
scientific  work  of  any  kind,  except  that  practised  by  the  attending  physician,  with 
his  trained  ear  and  finger  and  eye,  in  the  physical  examination  of  his  patient  at  the 
bedside. 

To-day  the  duties  of  the  intern  are  almost  exclusively  scientific  in  progressive 
institutions.  He  is  charged  with  the  taking  of  the  histories  of  his  cases,  with  making 
at  least  a  preliminary  physical  examination,  and  he  is  expected  to  make,  or  know  how 
to  make,  urine  examinations,  blood  examinations,  to  make  blood-counts  of  all  sorts, 
to  measure  the  hemoglobin,  to  take  the  blood-pressure,  and  to  interpret  all  of  these 
findings  in  the  light  of  the  scientific  literature  of  his  profession.  He  is  expected  to 
be  a  master  of  the  microscope,  and  to  make  diagnosis  from  tissue  taken  from  the 
operating-table.  Not  only  this,  the  intern  in  the  modern  hospital  is  expected  to 
work  out,  under  the  direction  of  the  attending  physician,  some  definite,  original 
investigation  into  the  etiology  and  pathology  of  disease  with  material  gathered  at 
the  bedside  of  his  patients. 

But  the  preliminary  equipment  of  the  young  physician  intended  for  this  sort 
of  work  has  grown  quite  in  step  with  his  duties.  Nearly  all  first-class  medical  schools 
to-day  require  a  high  order  of  preliminary  education.  A  few  of  them  accept  only 
college  graduates,  and  hardly  any  of  the  schools  worth  mentioning  admit  a  student 
who  has  not  had  at  least  some  college  training.  In  most  of  the  universities  there 
are  special  courses  for  men  who  expect  to  study  medicine,  and  they  are  taught 
physiology,  organic  and  inorganic  chemistry,  biology,  botany,  and  microscopy 
in  preparation  for  the  strictly  medical  training.  In  a  few  more  years  no  man 
who  has  not  had  this  training  will  be  eligible  for  admission  into  any  first-class  med- 
ical school. 


HOUSE    MEDICAL    STAFF  285 

Then,  these  young  men  have  at  least  four  years  of  grinding  work  in  the  various 
branches  of  medicine,  a  great  deal  of  time  being  spent  at  the  bedside  and  in  the 
laboratories  of  good  hospitals,  so  that  when  they  are  graduated  they  have  a  fine 
foundation  upon  which  to  build  a  highly  specialized  career  in  their  chosen  profes- 
sion. 

The  men  who  are  thus  well  equipped  almost  all  find  places  in  the  large  pro- 
gressive hospitals,  at  the  present  time,  where  there  are  medical  staffs  of  high  attain- 
ment and  modern  learning,  and  pathologic  departments  presided  over  by  thor- 
oughly trained  scientific  men.  It  goes  without  saying  that  these  men  in  such 
institutions  achieve  the  highest  possible  order  of  success,  not  only  during  their 
intern  days,  but  afterward. 

Anything  short  of  these  standards  of  internship,  both  as  to  preliminary  equip- 
ment and  service,  must  be  makeshifts  in  institutions  that,  because  of  their  poverty 
or  small  size,  or  both,  cannot  afford  to  command  the  highest  order  of  talent. 

Just  here,  in  passing,  it  might  be  suggested  that  the  small  hospital  could  well 
afford  to  pay  for  the  services  of  at  least  one  young  man  who  has  had  a  complete 
training  in  some  high-class  hospital,  and  who  would  enter  with  a  progressive  and 
scientific  spirit  into  the  work  about  him,  to  the  end  that  the  institution  would 
progress,  at  least  in  a  small  measure,  commensurate  with  the  possibilities  of  the 
time. 

Usually  interns  serve  two  years  in  the  hospital,  one  year  as  junior  and  one  year 
as  senior.  There  are  variations  in  this  regard,  especially  where  there  are  perma- 
nent services  in  the  institution,  but  in  the  majority  of  the  hospitals  of  this  country 
this  is  the  term  of  service  of  internship,  and  the  specific  duties  of  these  young  men 
can  be  pretty  well  defined  along  logical  lines.  In  some  hospitals,  especially  the 
larger  ones,  there  are  regular  house  physicians  in  the  several  departments,  men  who 
have  graduated  from  their  internship,  and  who  are  given  third  or  even  fourth  year 
work  to  fit  them  as  specialists.  This  is  an  excellent  system  for  several  reasons :  in 
the  first  place,  it  gives  the  attending  physicians  a  higher  order  of  expert  assistance, 
and  to  that  extent  is  in  the  direct  interest  of  the  patients;  next,  it  gives  an  excellent 
special  training  in  some  chosen  branch  to  a  young  man  whose  counterpart  of  several 
years  ago  had  to  go  to  Europe  for  that  finishing  course. 

Duties  of  Junior  Intern. — Let  us  take  the  junior  intern  immediately  upon 
his  admission  to  the  hospital,  and  follow  him  through  his  various  routine  duties, 
as  those  duties  seem  to  fall  to  him  naturally. 

The  place  at  which  his  service  will  begin  is  the  laboratory  of  pathology,  where 
he  should  have'a  training  of  at  least  two  or  three  months  in  urinalysis,  blood  exami- 
nation, and  clinical  pathology  under  the  immediate  direction  of  the  very  best  talent 
obtainable.  Naturally,  if  the  full  corps  of  junior  interns  is  taken  into  the  hospital 
at  one  time,  it  will  be  impossible  for  all  of  them  to  get  their  laboratory  training  be- 
fore they  are  sent  to  the  wards.  This  is  a  misfortune,  the  only  cure  for  which  is  to 
give  the  men  a  part  of  their  laboratory  training  before  they  are  officially  entered  as 
interns.  In  many  schools  the  men  graduate  some  months  before  the  time  arrives 
for  them  to  enter  the  hospital  to  which  they  are  appointed,  and,  when  this  is  the 
case,  they  can  be  given  a  good  deal  of  preliminary  training  before  their  formal  advent 
in  the  institution.  Different  hospitals  will  have  different  methods  of  arriving  at 
an  arrangement  by  which  all  the  men  can  go  into  the  wards  with  a  practical  labora- 
tory training.  The  main  thing  is  that  they  should  have  this  training  in  some  way 
at  the  very  earliest  possible  moment  in  their  hospital  careers. 

If  the  junior  intern  can  have  three  months'  laboratory  service,  one-third  of 
this  period  may  be  spent  on  urine  work,  and  he  should  be  trained  thoroughly  in  the 


286  OPERATION    OF   THE    HOSPITAL 

chemistry  and  bacteriology  of  normal  urines  and  the  departures  from  the  normal 
in  the  course  of  disease,  and  he  should  be  compelled  to  study  hard  in  the  litera- 
ture concerning  the  significance  of  urine  pathology.  His  second  month  may  be 
devoted  to  blood  work,  the  first  phase  of  which  will  be  blood-counts,  white  and  red, 
and  the  differentials.  He  should  have  a  severe  practical  drill  in  the  physiology  and 
pathology  of  the  blood,  using  the  material  of  the  hospital  wards.  He  should  be 
taught  the  technic  of  blood  bacteriology  and  the  significance  of  the  blood-pressure, 
the  hemoglobin,  the  Widal  and  Wassermann  tests,  the  various  tuberculin  tests, 
and  their  reactions  and  value.  During  this  period  he  should  be  given  a  sufficient 
amount  of  milk  investigation  to  make  him  familiar  with  the  technic  of  milk  exam- 
inations— physiologic,  bacteriologic,  and  chemic.  This  work  in  milk  need  not  go 
into  speculative  fields,  but  there  are  certain  definite  agreed  constituents  of  milk, 
physiologic  as  well  as  bacteriologic,  and  these  things  the  first  year  intern  ought  to 
know. 

The  third  month  of  the  intern's  stay  in  the  laboratory  may  be  most  profitably 
spent  in  clinical  pathology — the  examination  of  tissue  from  the  operating-table  and 
the  identification  of  morbid  growths.  This  month's  work  may  also  take  him  back 
into  the  field  of  blood  pathology,  and  his  training  at  this  period  should  also  include 
a  study  of  blood-serum  and  the  various  branches  of  serum  therapy,  the  vaccines, 
and  antitoxins.  Naturally,  these  latter  studies  would  more  properly  come  during 
the  second  month,  in  connection  with  his  blood  work,  but  they  might  be  also 
classified  as  a  finishing  course  in  blood  study,  and  he  will  probably  have  more 
time  to  do  this  work  and  be  better  equipped  to  understand  it  than  if  it  had  come 
earlier  in  his  training. 

Nearly  every  hospital  nowadays  does  certain  of  its  pathologic  work  and  micro- 
scope analysis  in  small  auxiliary  laboratories,  located  at  some  point  convenient 
to  the  various  wards,  and  a  good  deal  of  the  laboratory  work  can  be  done  there  by 
the  junior  intern.  There  are  two  or  three  reasons  why  these  small  department 
laboratories  are  advantageous,  the  chief  of  which  is  the  personal  equation.  Nearly 
every  attending  physician  and  surgeon  has  pretty  definite  notions  of  his  own  con- 
cerning the  laboratory  work  that  he  wants  done  on  individual  patients,  and  he  will 
want  to  see  the  results  of  this  work  without  having  to  folloAV  the  specimen  to  the 
main  laboratory  of  the  institution;  therefore,  he  gives  his  orders  to  the  junior 
intern,  who  carries  them  out  personally  in  the  auxiliary  laboratory,  where  the 
specimen  can  be  saved  for  him  and  shown  to  him  by  the  man  who  has  done  the 
work.  Thus  there  can  be  a  definite  study  of  the  individual  case,  correlating  the 
laboratory  finding  with  the  clinical  picture,  which  is  an  immensely  important  thing 
in  diagnosis.  There  is  also  a  great  saving  of  time  where  these  auxiliary  laboratories 
are  operated.  Let  us  say  there  is  a  case  of  nephritis,  or  any  of  the  lesions  in  which 
there  are  variable  quantities  of  albumin  and  sugar  in  the  urine;  the  intern  who  is 
examining  the  urine  of  a  given  patient  every  day,  or  at  stated  intervals,  will  soon 
come  to  have  the  daily  recurring  picture  in  his  mind,  and,  at  a  glance,  will  be  able 
to  tell  whether  the  albumin  or  sugar  is  increasing  or  decreasing  without  very  much 
of  a  quantitative  examination,  and,  while  it  requires  onty  a  moment  to  obtain  a 
sugar  or  albumin  reaction,  it  requires  many  minutes  to  make  a  complete  urine 
examination.  If  the  specimen  goes  to  the  general  laboratory  of  the  hospital  there 
is  no  individualism  in  the  specimen,  and  the  man  who  does  the  work  has  no  notion  of 
the  peculiarities  of  the  case.  Therefore,  he  is  compelled  to  make  a  complete  exam- 
ination and  send  up  a  complete  report,  whereas  the  intern  on  the  case,  working 
in  his  little  cubby-hole,  can  make  a  better  finding  at  infinitely  less  pains  from  the 
view-point  of  the  physician  in  the  case.     There  is  another  saving :  it  too  often  hap- 


HOUSE    MEDICAL   STAFF  287 

pens  that  the  attending  physician  orders  a  daily  urinalysis  or  an  hourly  blood-count, 
and  the  nurse,  in  her  zeal  to  obey  instructions,  sends  the  specimen  to  the  laboratory 
for  weeks  and  even  months  after  it  has  ceased  to  be  useful  unless  she  is  stopped; 
then,  again,  a  good  many  visiting  physicians  ask  for  urine  and  blood  examination 
just  as  a  routine  practice,  and  the  intern,  making  the  rounds  with  his  senior,  will 
rarely  interfere  unless  he  is  having  the  work  to  do  himself,  in  which  case  he  will 
often  be  able  to  call  the  attention  of  the  attending  physician  to  the  fact  that  he  is 
very  busy,  and  get  the  order  called  off.  So  that  from  every  conceivable  stand- 
point the  auxiliary  laboratory  is  an  advantage  in  economy  and  efficiency. 

The  next  most  important  duty  of  the  junior  intern,  after  he  arrives  on  the  wards 
of  the  hospital,  is  history  taking.  This  is  an  immensely  important  part  of  the  exam- 
ination of  the  patient,  leading  up  to  diagnosis;  so  important,  indeed,  that  nearly 
every  hospital  staff  member  has  at  some  time  in  his  career  created  for  himself  some 
special  system  of  history  writing,  and  there  are  almost  as  many  systems  in  exist- 
ence as  there  are  physicians  in  practice.  We  go  into  this  question  of  history  writing 
so  completely  in  our  section  on  the  Records  of  Patients  that  we  will  pass  over  it 
for  the  present. 

These  two  duties,  that  of  doing  the  laboratory  work  and  that  of  writing  the 
histories,  are  the  only  ones  definitely  assigned  to  the  junior  intern  in  the  hospital, 
merely  because  he  is  a  junior  intern.  In  addition  to  these  duties,  he  should  share 
with  his  senior  the  privilege  of  accompanying  attending  physicians  upon  the  rounds 
of  the  hospital,  taking  orders,  getting  his  first  lessons  in  physical  diagnosis,  and  in 
the  treatment  of  patients.  He  should  be  allowed,  likewise,  a  share  in  attending 
the  visiting  physician  on  the  rounds  of  the  private  cases,  so  that  he  may  learn  some- 
thing of  the  ethics  of  his  profession,  how  to  handle  sick  patients  of  the  higher  classes, 
how  to  meet  their  relatives,  and  to  act  diplomatically  and  tactfully  in  dealing  with 
them,  and  he  should  be  expected  to  always  be  on  the  wards  of  the  hospital  during 
the  regular  visiting  hours  of  the  institution,  not  only  for  the  purpose  of  guarding 
the  patients  from  undue  annoyance  by  their  own  or  other  visitors,  but  for  the 
purpose  of  answering  pertinent  questions  of  anxious  relatives;  no  matter  that  the 
patients  are  poor  and  illiterate — they  are  human  and  suffering,  and  they  have 
relatives  who  are  anxious  about  them,  and  who  are  entitled  to  courteous  answers 
to  their  inquiries  as  to  the  probable  duration  of  the  patient's  illness,  his  likelihood 
to  recover,  and  to  smooth  out  any  unnecessary  misgivings  concerning  the  case. 

Where  the  medical  department  of  the  hospital  is  a  very  heavy  service,  the  junior 
intern  will  always  have  to  divide  with  his  senior  the  duty  of  watching  the  detailed 
care  of  patients  at  the  hands  of  the  nurses  and  orderlies.  If  he  does  not  catheterize, 
he  should  see  that  that  service  is  properly  performed.  He  should  see  that  typhoid 
and  pneumonia  cases  are  properly  tubbed  for  reduction  of  temperature,  and  he 
should  be  almost  constantly  about  the  wards  to  watch  after  the  personal  comfort  of 
his  patients,  and  to  exercise  perhaps  a  greater  amount  of  discretion  in  carrying  out 
the  attending  physician's  orders  than  would  be  allowed  a  nurse  or  an  orderly. 

Surgical  Department. — In  a  good  many  hospitals  the  junior  interns  in  the 
surgical  section  give  the  anesthetics.  There  are  many  surgical  operations  whose 
chief  danger  lies  in  the  general  anesthetic,  and  it  would  seem  that  this  procedure 
is  important  enough  and  sufficiently  scientific  to  engage  the  lust  attention  of  well- 
trained  men.  In  some  institutions  there  are  regularly  employed  and  highly  trained 
medical  or  non-medical  women,  whose  only  duty  is  to  give  the  anesthetics;  and, 
where  there  is  peculiar  fitness  on  the  part  of  the  individual,  this  is  all  right,  but  as 
a  rule  or  practice  it  can  hardly  be  countenanced.  Anesthetics  affect  individuals 
differently,  not  only  because  the  individuals  themselves  differ  in  their  physiologic 


288  OPERATION   OF   THE    HOSPITAL 

make-up,  but  because  of  the  nature  of  the  disease  from  which  they  are  suffering, 
as,  for  instance,  heart  cases  and  nephritics,  patients  who  have  bad  lungs,  and  the 
like,  and  oftentimes  in  the  course  of  an  anesthetic  there  comes  over  the  patient 
almost  an  instant  change,  which  the  medically  trained  person  will  recognize  at 
once  as  the  effect  of  the  anesthetic  on  a  peculiarly  susceptible  patient,  and  with  this 
change  will  come  the  necessity  for  immediate  action  to  bring  relief.  It  would  seem 
that  the  frequency  of  these  emergencies  would  plead  in  favor  of  a  skilful  anesthetist 
who  has  had  a  careful  medical  training.  If  these  premises  are  logical,  it  naturally 
follows  that  the  junior  intern  is  not  a  good  anesthetist,  and  that  this  important 
work  ought  to  be  laid  upon  more  responsible  shoulders;  but  in  most  operative  sur- 
gical procedures  of  the  present  day  the  surgeon  can  advantageously  use  two  assist- 
ants: one,  the  senior,  who  will  stand  opposite  him  and  give  him  trained  technical 
assistance,  and  the  other,  who  will  hold  retractors,  move  extremities,  and  do  other 
work  of  not  quite  so  technical  a  character,  and  it  would  seem  that  the  junior  intern 
ought  to  be  allowed  to  do  this  work  in  preparation  for  his  subsequent  more  respon- 
sible duties.  In  this  department,  also,  the  junior  intern  may  have  an  opportunity 
to  assist  in  putting  on  plaster  casts  and  various  surgical  splints,  including  the  various 
suspension  splints.  He  will  have  learned  also,  in  the  course  of  his  laboratory  ex- 
perience, to  make  lumbar  puncture,  do  venesections,  and  the  various  transfusions; 
as  a  rule,  too,  the  junior  does  at  least  part  of  the  dressings.  Sometimes  the  senior 
will  take  the  clean  dressings  and  the  junior  the  infected  or  open  cases. 

Obstetric  Department. — In  the  obstetric  department  it  is  the  rule  in  most  insti- 
tutions to  allow  the  junior  intern  to  participate  in  the  delivery  of  patients  during 
the  presence  of  the  attending  obstetrician,  and  to  be  generally  helpful  in  the 
delivery  room.  He  should'  be  charged  with  looking  after  the  infant  immediately 
upon  its  delivery,  the  washing  of  the  eyes  with  prophylactic  solution,  the  care  of 
the  cord,  the  examination  and  measurement  of  the  placenta  for  the  detection  of 
retained  particles;  then,  immediately  after  the  infant  is  tagged  and  taken  from  the 
delivery  room,  it  should  be  his  duty  to  take  its  measurements  and  weights.  In 
institutions  where  outside  physicians  are  allowed  the  courtesies  of  the  maternity 
department,  it  should  be  the  duty  of  the  junior  intern  to  see  that  the  outside 
physician  is  inducted  into  the  mysteries  of  the  department  technic,  to  see  that  he 
reads  the  few  rules  for  attending  men  in  regard  to  the  wearing  of  gloves,  the  scrub- 
bing up  processes,  and  the  other  essential  points  in  a  well-regulated  maternity  de- 
partment. In  some  institutions  a  good  many  of  these  duties  are  left  to  the  nurses, 
and  there  can  be  no  valid  argument  against  this,  excepting,  perhaps,  that  an  intern 
may  more  diplomatically  lead  an  attending  physician  into  proper  channels  than  the 
nurse,  but  the  junior  intern  should  at  least  know  how  to  do  these  things,  and  how 
to  regulate  the  department  in  the  absence  of  his  senior  or  the  staff  obstetrician. 

Other  Departments. — The  specific  duties  of  the  junior  intern  for  the  department 
of  medicine,  surgery,  and  obstetrics  will  naturally  follow  in  the  other  departments 
of  the  hospital,  as,  for  instance,  the  junior  in  the  pediatric  service  will  in  all  medical 
cases  follow  the  routine  of  the  practice  in  the  medical  department,  and  in  the  sur- 
gical cases  he  will  follow  the  practice  in  the  surgical  department.  In  such  special- 
ties as  gynecology,  the  eye,  ear,  nose,  and  throat,  and  in  the  section  on  genito-urinary 
surgery  the  duties  of  the  junior  will  be  obvious. 

In  the  children's  department,  where  the  institution  has  an  isolation  building, 
there  will  usually  be  a  special  intern,  who  will  be  thoroughly  trained  in  the  pro- 
phylaxis against  carrying  infections  from  one  class  of  diseases  to  another.  If  this 
isolation  service  is  a  very  small  one,  and  the  discipline  of  the  interns  is  rigid,  the 
junior  intern  will  not  infrequently  be  allowed  to  take  care  of  the  infectious  diseases, 


HOUSE    MEDICAL   STAFF  289 

under  mosl  rigid  directions  as  to  the  carrot'  bis  hands,  clothing,  and  person  generally; 

but  oftencr,  and  perhaps  more  properly,  the  care  of  the  communicable  infections 
will  be  restricted  to  the  more  responsible  and  hence  more  careful  members  of  the 
attending  staff. 

Duties  of  Senior  Interns. — The  senior  interns  are  supposed  to  have  had  junior 
service  in  all  the  departments  of  the  hospital  in  which  they  are  working  as  seniors, 
and,  upon  arrival  at  their  seniority,  are  supposed  to  be  equipped  to  represent  the 
attending  physician  during  his  absence.  They  will,  of  course,  have  junior  interns 
under  them,  and,  if  they  are  to  be  held  responsible  for  the  care  of  patients,  they 
must  be  clothed  with  authority  over  their  juniors,  so  that  they  can  apply  some  sort 
of  system  in  getting  the  work  done.  They  will  not,  of  course,  have  disciplinary 
power  over  the  junior  interns,  and  can  only  report  their  derelictions  to  the  super- 
intendent of  the  hospital,  who  will  naturally  back  up  their  requirements  to  any 
reasonable  extent.  It  should  be  the  duty  of  the  senior  intern  to  see  that  the  junior 
writes  the  history  in  all  cases  admitted,  promptly  and  efficiently,  and  the  senior 
will  also  see  that  the  junior  does  whatever  laboratory  work  may  be  required  for 
the  presentation  of  the  case  in  a  proper  manner  on  the  next  visit  of  the  attending 
physician. 

The  senior  intern  is  charged  with  the  duty  of  making  the  physical  examina- 
tions of  all  ward  eases,  preliminary  to  presentation  to  the  visiting  physician. 

Sometimes  the  attending  physicians  prefer  to  make  this  physical  examination 
themselves;  there  are  two  advantages  in  having  the  senior  intern  do  this  work: 
First,  so  that  he  may  order  the  necessary  laboratory  work  on  the  patient,  in  the 
light  of  the  clinical  picture,  which  can  be  reported  to  the  visiting  physician  upon  his 
first  introduction  to  the  case;  second,  the  making  of  the  physical  examination  by 
the  senior  is  most  excellent  intern  practice,  as  he  can  be  checked  up  on  his  diag- 
nosis by  the  visiting  physician  in  whose  service  he  is  working. 

It  naturally  will  be  the  duty  of  the  senior  intern  to  perform  such  minor  tech- 
nical operations  as  venesections,  subcutaneous  and  intravenous  normal  salt  irriga- 
tions, spinal  punctures,  and  the  injection  of  whatever  vaccines  and  serums  may  be 
prescribed,  always  subject  to  direction  by  the  attending  physician,  of  course. 

The  senior  intern  in  the  surgical  service  and  the  various  surgical  specialties 
will  naturally  act  as  first  assistant  to  the  operating  surgeon,  at  least  in  all  ward 
cases.  Sometimes  the  surgeons  have  a  private  assistant  of  their  own  whom  they 
require  to  assist  them  at  operations  upon  their  private  patients,  and  these  private 
assistants  are  a  bone  of  much  contention  in  a  good  many  institutions.  Naturally 
the  surgeon  has  a  perfect  right  to  demand  a  high  order  of  service  in  his  surgical 
operations,  and  oftentimes  a  very  exacting  surgeon,  who  happens  not  to  approve 
the  class  of  assistance  given  him  by  the  particular  senior  intern  who  serves  him, 
will  wish  to  call  in  his  own  private  assistant,  even  on  free  or  ward  cases,  and  it  is 
a  serious  question  how  far  a  hospital  administrator  may  go  in  his  insistence  that 
the  house  senior  intern  shall  be  first  assistant  to  the  operator.  It  would  seem 
equitable  that  the  operating  surgeon  should  accept  the  assistance  of  his  senior 
intern,  other  things  being  equal,  in  all  operations  on  free  patients,  and  in  the 
cases  of  all  those  who  pay  a  very  small  sum  for  their  keep  in  the  hospital  and  who 
do  not  pay  a  fee  to  the  surgeon;  but  at  the  same  time  the  surgeon  is  responsible 
for  his  work,  and  he  will  probably  he  quite  as  insistent  about  expert  help  on  the 
ward  cases  as  on  private  ones;  and  who  shall  insist  that  he  use  an  intern  he  regards 
as  incompetent,  especially  since  it  is  common  knowledge  that  suits  for  malprac- 
tice are  oftenest  brought  by  this  class  of  patients? 

By  the  very  nature  of  things,  the  senior  intern,  who  assists  his  chief  in  surgical 


290  OPERATION    OF   THE    HOSPITAL 

operations,  must  do  the  clean  dressings,  and  should  keep  himself  clean  to  that  end, 
because  at  any  moment  he  may  be  called  upon  to  go  into  a  clean  wound  with  his 
chief,  and  the  junior  intern  may  well  be  charged  with  the  duty  of  doing  the  dress- 
ings in  pus  cases. 

Since  the  senior  intern  assists  his  chief  in  surgical  operations,  it  falls,  of  course, 
that  the  same  intern  should  write  up  for  the  record  the  gross  pathology  of  all 
surgical  operations  performed  at  which  he  is  present  as  first  assistant. 

The  above  division  of  departments,  as  between  the  junior  and  senior  intern, 
will  hold  as  a  general  rule  in  the  average  hospital.  Most  visiting  physicians  and 
surgeons  will  want  the  continued  service  of  one  man  to  take  orders  on  individual 
private  cases  during  the  whole  case,  and  sometimes  the  duties  of  the  junior  and  se- 
nior will  be  so  divided  up  that  a  junior  intern  will  be  compelled  to  make  rounds  with 
the  chief  of  the  department,  and  it  will  be  necessary  for  him  often  to  continue 
constantly  on  certain  very  special  cases  in  the  house,  such,  for  instance,  as  those  in 
which  the  attending  physician  may  apprehend  some  serious  and  sudden  emergency. 
It  will  make  very  little  difference  in  such  cases  whether  the  intern  is  a  junior  or 
senior,  but  may  make  a  vast  difference  whether  he  has  been  given  such  explicit 
orders  as  will  enable  him  to  meet  such  an  emergency. 

Methods  of  Choosing  Interns. — It  is  impossible  to  fix  hard-and-fast  rules  for 
the  choosing  of  interns.  In  every  method  there  are  difficulties  and  disadvantages, 
and  a  method  that  would  be  ideal  for  one  institution  would  not  do  at  all  for  another. 
There  are  some  hospitals  that  will  always  have  difficulty  in  securing  a  sufficient 
number  of  competent  young  men  to  do  the  work  in  the  institution,  first,  because 
these  small  hospitals  are  usually  not  very  well  equipped  to  do  a  high  order  of  scien- 
tific work;  they  have  no  high-class  paid  pathologist  to  train  these  young  men  in 
one  of  the  most  essential  features  of  their  education,  and,  therefore,  the  best  men  will 
choose  larger  and  more  roundly  equipped  hospitals  where  they  can  get  a  better 
training;  then,  again,  in  the  smaller  hospitals  the  material  in  the  shape  of  patients 
will  be  more  or  less  limited;  and,  third,  usually  these  smaller  hospitals  cannot  afford 
the  proper  paid  help  to  do  the  menial  work,  and  they  are  sometimes  short  of  nurses, 
and  the  interns  will,  therefore,  often  be  called  upon  to  do  work  which  they  regard 
as  that  of  a  nurse,  or  even  of  a  menial,  and  they  do  not  take  to  this  sort  of  work, 
especially  in  view  of  the  fact  that  in  the  larger  institutions  their  duties  are  so  differ- 
ent. However,  there  are  some  very  fundamental  thoughts  that  ought  to  underlie 
the  choosing  of  interns  even  in  small,  not  very  well-supported  institutions. 

One  of  the  very  worst  things  that  can  happen  to  a  hospital  is  to  be  compelled 
to  accept  for  an  intern  the  son  or  protege  of  some  influential  man  in  the  insti- 
tution, a  member  of  the  board  of  directors,  a  powerful  member  of  the  medical  staff, 
or  a  consequential  contributor.  The  disadvantage  of  this  sort  of  an  intern  is  not 
confined  to  the  small  hospital,  but  is  present  wherever  such  an  intern  is  accepted. 
The  first  one  may  be  a  high-class,  ideal  young  man  in  every  way,  and  he  may  per- 
form his  duties  so  equitably  that  this  method  of  choosing  interns  will  become  a 
fixed  custom  in  the  institution,  and  continuously  a  number  of  men  whose  influence 
has  secured  their  positions  for  them  may  all  be  most  acceptable  young  physicians, 
but  there  will  almost  inevitably  come  a  time  when  the  custom  will  be  abused,  and 
some  unworthy  young  man  will  get  in  by  reason  of  his  social  or  professional  influ- 
ence, and  one  man  of  this  class  can  undiscipline  and  disorganize  a  whole  institu- 
tion. Oftentimes  his  conduct  will  be  in  utter  defiance  of  rules  and  of  the  discipline, 
and  he  will  often  attempt  to  overrule  orders  by  the  superintendent. 

If  direct  appointments  of  interns  must  be  made  by  the  board  of  directors  or 
by  the  medical  staff,  without  any  examination  of  the  qualifications  of  the  applicants, 


HOUSE    MEDICAL   STAFF  291 

it  is  very  far  better  to  inaugurate  some  system  of  choice  that  will  prohibit  the  fasten- 
ing upon  the  institution  of  some  unworthy  protege  of  some  strong  supporter. 
One  method  of  such  choice  is  to  leave  the  matter  to  the  dean  of  the  nearest  or  most 
favorably  situated  medical  school,  or  the  registrar  of  the  school,  who  can  present 
the  opportunity  afforded  by  the  hospital  to  the  senior  students,  and  very  often 
some  excellent  young  men  can  be  secured  in  this  way,  especially  if  it  does  not  neces- 
sitate their  coming  up  for  a  competitive  examination.  There  are  a  number  of  small 
hospitals  that  secure  a  rather  high  order  of  interns  in  this  way. 

A  good  many  small  special  hospitals,  such  as  sanitariums  and  invalid  homes  of 
various  sorts,  pay  a  small  amount  for  their  interns,  and  get  them  from  the  large 
institutions  after  they  have  served  a  year  or  two.  A  good  many  of  these  young 
men  are  poor,  and  need  to  make  a  little  money  before  starting  out  upon  their  careers 
of  medical  practice;  and  very  often,  for  $25  or  $50  per  month,  excellent  young  men 
can  be  had  by  this  sort  of  fellowship.  Some  of  these  institutions  employ  one  good 
ex-intern  of  a  large  hospital,  and  then  appoint  the  balance  of  the  corps  in  some  other 
way  and  without  paying  them;  they  may  be  fresh  out  of  school,  chosen  perhaps  in 
the  manner  first  named,  that  is,  by  appointment  on  recommendation  of  the  dean 
or  registrar  of  a  medical  school. 

The  direct  method  of  appointment  of  interns,  without  recourse  to  any  examina- 
tion whatever,  is  quite  as  mimic  to  the  best  interest  of  the  large  hospitals  as  the 
smaller  ones,  and  for  the  same  reasons,  so  that  to-day  in  nearly  all  of  the  large  insti- 
tutions of  the  country  the  choice  of  interns  is  by  some  method  looking  to  compe- 
tition. Sometimes  the  competition  is  in  the  shape  of  a  written  examination  only; 
sometimes  it  is  oral  only;  sometimes  a  combination  of  the  two,  and  in  a  few  instances, 
another  phase  is  added  by  way  of  a  personal  inquiry  into  the  habits  and  morals  of 
the  candidates,  and  they  are  marked  on  these  virtues  and  personal  vices  in  the  same 
way  as  in  the  written  and  oral  examinations.  A  good  many  hospitals  are  directly 
affiliated  with  medical  schools,  and,  where  this  is  the  case,  the  choice  of  interns 
must  be  made  from  the  students  of  the  school,  oftentimes  without  any  further  in- 
quiry than  the  markings  of  the  students  during  their  undergraduate  examinations; 
that  is,  the  highest  men  in  each  class  are  given  the  intern  positions  in  the  hospital 
attached  to  the  school. 

But,  as  an  abstract  proposition,  the  competition  method  of  choosing  interns  is 
pretty  well  established,  and  the  experience  of  years  has  led  to  a  definite  routine  in 
the  choice  of  these  young  men — almost  to  a  technic,  it  would  seem. 

The  first  step  in  this  competitive  procedure  is  to  post  a  notice  of  examination 
for  internship  in  the  institution  on  the  bulletin  boards  of  the  medical  schools  whose 
students  are  invited  to  participate,  and  this  notice  calls  for  the  personally  written 
application  of  those  young  men  about  to  graduate  who  desire  to  take  the  exami- 
nations, and  who  are  asked  to  file  with  their  applications  such  letters  of  commenda- 
tion as  they  can  secure,  preferably  from  the  officers  of  the  school  and  from  the  lead- 
ing men  of  their  home  towns — ministers,  physicians,  and  the  like.  The  adminis- 
trators of  the  hospital  have  their  first  opportunity,  in  these  written  applications, 
to  cull  out  any  undesirable  candidates,  if  such  are  found,  early  in  the  procedure. 

The  next  step  is  to  request  the  presence  of  the  applicants  in  person  at  the 
institution  at  some  appointed  hour,  ostensibly  for  the  purpose  of  registering  for 
the  examinations,  but  in  reality  for  the  purpose  of  a  review  before  some  com- 
mittee, preferably  one  composed  of  an  equal  number  of  the  members  of  the  board 
of  directors  and  of  the  medical  staff;  but  care  should  be  taken,  when  medical  men 
are  chosen  for  membership  on  this  committee,  to  see  that  the  same  men  are  not 
later  chosen  to  conduct  the  examinations.     The  young  men  can  be  ushered  before 


292  OPERATION    OF   THE    HOSPITAL 

this  joint  committee  one  at  a  time,  their  names  and  addresses  and  home  towns  can 
be  taken,  the  personality  of  the  applicant  in  each  case  can  be  considered  by  this 
joint  committee,  and,  upon  the  exit  of  each  one,  some  appointed  member  of  the 
committee  can  set  down  the  relative  marking  of  the  candidate.  If  he  is  of  excellent 
personality,  and  apparently  in  every  way  a  desirable  man  for  an  intern,  he  can  be 
marked  AA,  or  100.  Sometimes  this  ordeal  will  eliminate  one  or  more  undesirable 
men  who  might  pass  excellent  written  and  oral  examinations,  but  whose  personality, 
for  one  reason  or  another,  would  seem  to  render  them  wholly  undesirable  as  interns, 
and  in  such  cases  it  would  seem  to  be  the  privilege  of  the  committee  or  its  executive 
officer,  the  superintendent  of  the  hospital,  to  privately  advise  such  applicant  not 
to  take  the  examinations. 

The  next  step  in  the  procedure  is  the  beginning  of  the  examinations,  written  and 
oral.  If  the  examinations  are  to  be  entirely  fair,  and  beyond  question  of  fairness, 
the  following  preparation  is  in  general  use : 

There  are  a  sufficient  number  of  envelopes  enclosing  a  card,  so  that  there  will 
be  one  for  each  applicant.  These  envelopes  and  the  enclosed  card  are  numbered 
from  one  up,  the  same  number  on  the  envelope  and  card.  These  envelopes,  with 
the  card  enclosed,  are  passed  around  as  the  applicants  sit  at  their  desks,  ready  to 
write.  The  men  are  required  to  take  the  card  from  the  envelope,  write  their  names 
on  it  on  the  same  side  as  the  number,  place  it  in  the  envelope  again,  and  seal  the 
latter.  Each  man  is  notified  that  he  will  bear  the  number  that  has  been  given  him 
throughout  the  examinations,  written  and  oral,  and  that  he  will  be  expected  to 
place  his  number  on  every  sheet  that  he  writes,  and  that  when  the  oral  examina- 
tion takes  place  he  will  introduce  himself  to  the  examiners  by  number  and  not  by 
name. 

The  sealed  envelopes  are  then  placed  in  a  receptacle,  usually  a  metal  box,  se- 
curely locked,  placed  in  the  vault  of  the  institution,  and  the  keys  will  be  handed  to 
some  responsible  person,  to  the  end  that  the  box  may  not  be  opened  again  for  any 
purpose  whatever  until  it  is  finally  opened  in  the  presence  of  the  applicants  them- 
selves, or  some  committee  agreeable  to  them,  or  in  the  presence  of  the  board  of 
directors  or  medical  staff  of  the  hospital,  for  the  purpose  of  ascertaining  the  names 
that  go  with  the  fortunate  numbers. 

It  is  usual  that  the  written  examinations  in  each  branch  of  medicine  are  con- 
ducted by  the  staff  members  in  that  branch ;  for  instance,  there  are  four  members  of 
the  surgical  staff,  and  the  examination  in  surgery  will  take  place  from  nine  until  ten, 
and  there  are  four  questions,  each  with  one  or  more  parts.  Each  surgeon  will 
write  a  question,  seal  it  in  an  envelope  for  security,  and  let  it  be  opened  the  moment 
that  the  examination  is  about  to  begin,  when  all  the  questions  will  be  written  on 
the  blackboard.  Sometimes  the  department  staffs  will  appoint  one  of  their  number 
to  conduct  the  written  examination  in  the  subject,  and  generally  he  is  aided  by 
one  or  more  members  of  the  house  staff  of  the  hospital  or  by  the  superintendent 
of  the  institution.  Sometimes  the  members  of  the  staff  merely  hand  in  their  ques- 
tions, and  the  superintendent  of  the  institution,  to  save  the  time  of  the  attending 
physicians,  will  conduct  the  examination,  aided  by  some  of  his  interns.  Usually 
the  examinations,  both  written  and  oral,  will  include  medicine,  surgery,  obstetrics, 
gynecology,  pediatrics,  and  pathology,  the  latter  including  bacteriology  and  urin- 
alysis, and  the  other  branches  will  naturally  include  the  specialties  that  are  related 
to  them. 

At  the  close  of  the  written  examination  the  papers  will  be  examined  by  the 
men  who  have  prepared  the  questions,  each  member  of  the  staff  marking  only  the 
answers  to  the  question  that  he  has  handed  in.     It  is  oftentimes  very  difficult  to 


HOUSE    MEDICAL    STAFF  2(J3 

get  the  members  of  the  staff  to  take  the  necessary  time  to  mark  the  papers,  in  which 
case  that  ciuty  is  relegated  to  some  of  the  younger  men,  ex-interns  or  adjunct  mem- 
bers of  the  staff,  and  these  younger  men  confer,  before  beginning  their  work,  with 
the  men  who  have  asked  the  questions,  so  that  there  will  be  uniformity  in  the 
markings,  and  so  that  the  markers  can  follow  the  ideas  of  the  staff  members  as 
to  the  relative  value  of  the  different  sections  of  the  question  and  the  relatively 
important  phases  of  it.  But  all  papers  should  be  marked  by  the  same  person  or 
persons  to  insure  fairness. 

The  oral  examinations  are  usually  held  by  two  or  three  members  of  the  staff 
in  the  various  branches  sitting  together,  and  this  would  seem  necessary,  because 
if  one  member  of  the  surgical  staff,  for  instance,  examined  groups  of  the  men,  and 
others  examined  the  balance,  the  examiners  might  differ  very  materially  in  their 
estimate  of  the  answers,  and  so  inevitably  be  unfair  in  their  markings;  but,  where 
there  are  two  or  three  men  for  each  branch,  the  candidates  can  enter  the  room  one  at 
a  time  and  answer  the  questions  put  to  them  by  the  examiners,  and,  after  the  appli- 
cant has  left  the  room,  each  man  can  give  the  marking  he  thinks  proper;  if  there  are 
three  examiners,  the  three  marks  can  be  added  and  divided  by  three,  which  will 
give  a  fair  average  of  the  applicant's  percentage  in  the  oral  examination  in  that 
branch.  At  the  end  of  the  written  and  oral  examinations  a  committee  appointed 
for  that  purpose  can  take  the  percentages  in  the  written  and  in  the  oral  examinations 
and  in  the  personal  inquiry  that  was  made  by  the  first  joint  committee,  and  the 
sum  of  these  markings  divided  by  the  number  of  subjects  will  give  the  proper 
averages. 

Rotation  or  Permanent  Service. — There  is  no  doubt  that  the  ideal  intern  ser- 
vice, from  the  standpoint  of  the  patient  and  of  the  institution  and  the  attending 
physician,  is  one  in  which  the  men  are  continued  in  one  place  for  the  longest  possible 
time,  largely  because  they  become  efficient  to  an  extent  that  is  impossible  where 
frequent  changes  are  made,  and  many  hospitals  practice  this  continued  or  perma- 
nent service  of  the  intern  staff. 

Continued  service  in  one  department  of  a  general  hospital  is  attractive  to  the 
bright,  well-equipped  young  medical  man.  It  serves  to  bring  him  to  a  specialty 
in  his  profession  by  a  short  road,  but  it  may  be  fairly  doubted  whether  he  will  be 
able  to  go  very  far  in  his  specialty,  handicapped  by  the  limitations  of  such  a  train- 
ing. It  matters  little  whether  the  medical  man  is  a  general  practitioner  in  a  country 
town,  or  whether  he  is  a  specialist  in  some  particular  branch  in  a  large  city,  the 
measure  of  his  success  in  a  final  analysis  will  depend  upon  his  ability  to  make  diag- 
nosis of  disease.  The  intern  who  leaves  school  after  a  theoretic  training,  and  is 
immediately  given  service  in  the  surgical  section  of  a  large  hospital,  for  instance, 
may  become  a  most  expert  and  skilful  mechanic,  but  such  a  service  will  not  make 
him  a  good  diagnostician.  He  must  have  served  under  a  skilful  chief  in  the  medi- 
cal service  before  he  can  make  a  diagnosis  in  cases  of  abdominal  pathology  for 
instance;  and,  if  it  be  an  adult  female,  he  must  have  served  in  the  gynecologic  and 
obstetric  service  if  the  patient  is  to  get  the  largest  measure  of  profit  from  his 
knowledge  and  experience.  It  is  one  thing  to  do  a  surgical  operation  laid  down  in 
the  text-books  on  classical  lines,  but  it  is  a  vastly  different  thing  to  make  a  diagnosis 
and  to  determine  a  course  of  treatment  in  the  same  case,  and  the  man  with  one- 
sided training,  such  as  continued  service  in  one  department  of  the  hospital  would 
give,  can  never  hope  to  hold  his  own  with  the  trained  men  of  the  present  day. 

In  the  smaller  hospitals  the  interns  will  naturally  rotate,  or,  at  least,  they  will 
be  compelled  to  cover  a  good  deal  of  ground,  and  to  take  in.  perhaps,  at  the  same 
time,  several  classes  of  patients.     In  such  an  institution  the  training  will  depend 


294  OPERATION    OF    THE    HOSPITAL 

a  good  deal  on  their  superiors  and  the  scientific  work  they  are  compelled  to  do. 
In  the  large  municipal  institutions,  where  there  is  vast  material  in  every  department 
of  medicine  and  surgery,  it  would  seem  that  the  intern  should  be  given  a  careful, 
methodical  training  in  all  departments,  so  that,  if  he  should  then  desire  to  proceed 
along  some  special  line,  he  will  have  had  abundant  general  training  to  lead  up 
to  that.  In  a  few  institutions  in  this  country  an  attempt  is  being  made  just  now 
to  give  a  large  body  of  interns  a  general  training  in  all  of  the  departments,  and 
to  give  a  few  carefully  selected  men  special  training  as  a  sort  of  postgraduate 
course. 

Up  to  within  the  past  very  few  years  it  was  conceded  that  no  man  could  be  a 
well-rounded  out  specialist  in  any  branch  of  medicine  without  a  European  post- 
graduate training.  Recently,  however,  even  Europeans  concede  that  there  is  some 
merit  in  American  training,  and  a  few  of  the  large  institutions  are  prepared  to 
demonstrate  that  fact  by  giving  a  finishing  course  for  special  work  to  especially 
equipped  young  men  to  fit  them  for  practice  in  one  or  another  of  the  branches  of 
medicine. 

Two  or  three  of  the  departments  in  a  general  hospital  would  seem  to  suffer 
much  more  than  others  from  a  frequent  change  in  the  service  of  interns;  the  one 
most  vitally  affected  is,  of  course,  the  maternity  service,  and  the  one  that  suffers 
only  slightly  less  is  the  children's  department.  Very  great  harm  can  be  done  in 
almost  a  moment  in  the  maternity  department  by  inexperienced  or  inefficient  men, 
and  it  is  impossible  to  hope  that  the  intern  service  can  be  so  regulated  that  there 
will  always  be  present  for  every  occasion  an  experienced  visiting  obstetrician. 
A  young  man,  who  has  had  only  two  or  three  months'  obstetric  training,  is  hardly 
equipped  to  intelligently  examine  patients  with  a  view  to  ascertain  abnormalities 
and  to  lay  out  a  program  for  the  delivery. 

In  the  children's  department  the  particular  need  is  for  a  man  who  can  deter- 
mine the  difference  between  the  adult  and  the  child,  not  only  the  physical  signs  of 
disease  between  the  two,  but  for  purposes  of  surgical  diagnosis  and  operative  pro- 
cedure. Naturally,  also,  it  will  require  a  great  deal  of  experience  for  these  young 
men  to  make  early  diagnosis  of  the  communicable  infectious  diseases,  such  as  the 
exanthemata. 

Limited  Rotation. — Perhaps  there  is  a  happy  medium  somewhere  between  the 
continuous  intern  service  and  short  rotation.  For  instance,  the  young  man  who 
thinks  he  would  like  to  practice  obstetrics  as  a  career  must  know  a  good  deal  about 
gynecology,  and  ought  to  have  a  service  in  that  department;  the  obstetrician  must, 
of  course,  know  children  and  their  diseases,  and  he  ought  to  have  a  service  in  that 
department.  The  young  man  who  is  enthusiastic  enough  about  his  own  future  to 
select  the  profession  of  surgery  at  the  outset  of  his  career  will  not  only  want  to  do 
surgery  in  the  hospital,  but  he  must  have  a  thorough  training  in  medicine,  for  pur- 
poses of  diagnosis  and  differential  diagnosis.  He  ought  to  have  work  in  the  nose, 
throat,  and  ear  department,  in  the  genito-urinary  wards,  and  in  the  orthopedic, 
section  of  the  children's  department.  The  young  man  who  inclines  toward  internal 
medicine  must,  of  all  things,  have  a  thorough  training  in  the  laboratory  of  path- 
ology, bacteriology,  and  urinalysis,  and  it  will  not  be  quite  so  important  for  him  to 
see  very  much  surgery  or  the  special  surgical  branches. 

Naturally,  the  young  man  who  thus  chooses  a  specialty  for  himself  ought  to  be 
given  a  service  in  that  specialty  in  the  hospital,  immediately  after  he  has  had  a 
good  preliminary  training  in  the  laboratory  of  pathology.  He  will  acquire  in  his 
first  training  a  fair  idea  of  what  a  special  branch  contemplates,  and  he  will  go  into 
auxiliary  service  in  other  departments  with  a  good  deal  more  enthusiasm  than  if  he 


HOUSE    MEDICAL    STAFF  295 

were  put  into  these  first  without  having  been  led  up  to  them.  For  instance,  the 
young  prospective  surgeon  would  hardly  he  able  to  appreciate  the  surgical  necessi- 
ties in  the  field  of  diagnosis  until  he  had  had  actual  work  in  surgery,  but  he  could 
never  acquire  ability  as  a  diagnostician  without  service  in  the  medical  wards,  and 
his  first  service  in  surgery  would  convince  him  of  this. 

Ethics  of  Internship 

Relation  of  Interns  to  the  Superintendent  of  the  Hospital. — If  one  will  look 
about  the  country  to  find  the  well-conducted  hospitals,  he  will  soon  realize  that  the 
best  are  those  that  have  an  executive  officer  of  first-rate  ability,  and  one  of  the 
most  important  functions  of  the  executive  is  to  take  good  care  of  patients.  He 
cannot  do  this  without  the  best  of  intern  service,  and  he  cannot  have  such  service 
without  the  fullest  measure  of  authority  over  the  interns,  personally,  with  power 
to  discipline  them  when  necessary.  Therefore,  the  interns  in  the  hospital  ought 
to  be  directly  under  and  answerable  to  the  superintendent.  The  rules  for  these 
young  men  should  all  contemplate  responsibility  to  the  head  of  the  hospital.  These 
young  men  will  have  duties  that  involve  the  patients,  the  attending  physicians, 
the  training-school,  and  the  public,  but  there  can  be  no  divided  authority  that  will 
be  conclusive  or  final,  so  that,  in  all  of  their  dealings,  these  young  men  should  under- 
stand definitely  that  they  are  answerable  to  the  superintendent  of  the  hospital  and, 
as  a  finality,  to  no  one  else.  On  the  other  hand,  the  superintendent  of  the  hospital 
should  give  the  greatest  possible  consideration  to  these  young  professional  men. 
He  should  uphold  their  dignity  in  every  possible  way,  compel  obedience  to  their 
proper  professional  orders,  and,  when  a  plain  duty  necessitates  his  decision  that 
they  have  been  wrong  in  a  given  case,  it  is  highly  essential  that  the  decision  be 
rendered  in  such  a  way  that  the  position  of  the  intern  wiLl  not  be  made  untenable 
by  the  fact  that  a  nurse  or  a  junior  medical  man  has  reversed  his  orders. 

In  his  relations  to  the  interns,  it  will  be  the  duty  of  the  superintendent  of  the 
hospital  to  see  that  their  living  arrangements  are  pleasant,  that  their  quarters  are 
comfortable  and  well  furnished,  that  they  have  facilities  for  recreation,  quiet 
places  in  which  they  may  study,  that  their  food  is  wholesome,  well  cooked  and  well 
served,  even  if  plain.  These  young  men  have  usually  come  from  well-to-do  homes 
in  which  the  creature  comforts  are  present,  and  if  they  are  the  right  sort  of  young 
men  their  abilities  will  insure  for  them  in  the  future  the  personal  comforts,  and 
even  luxuries,  of  life.  So  that  in  this  formative  stage  of  their  careers  they  should 
be  made  as  happy  and  comfortable  as  possible.  There  seems  to  be  the  best  possible 
atmosphere  to  encourage  work,  and  interest  in  the  work  of  the  institution,  where 
the  superintendent  of  the  hospital  is  on  such  terms  with  these  young  men  that  they 
can  go  to  him  in  their  troubles,  confide  to  him  their  difficulties,  and  confess  to  him 
any  wrongdoing  or  negligence  of  which  they  may  have  been  guilty,  and  the  dis- 
cipline of  the  institution  will  hardly  ever  suffer  when  such  a  relationship  exists 
When  interns  are  found  fault  with  by  visiting  physicians,  their  superiors,  the  super- 
intendent of  the  hospital  will  hardly  do  his  whole  duty  in  such  a  case  without  an 
unprejudiced  examination  into  the  facts,  and  the  interns  ought  to  feel  that  their 
side  of  the  case  will  be  given  a  fair  hearing,  and  that  they  will  not  be  disciplined 
unless  they  have  deserved  it.  Sometimes  the  visiting  physician  will,  for  some 
reason,  take  a  peculiar  dislike  to  an  intern,  and  sometimes  unjustly  find  fault  with 
his  work;  sometimes,  too,  attending  physicians  are  tired  and  irritable  and  unrea- 
sonable— as  all  human  beings  are  on  occasion — but  that  is  no  reason  why  an  intern 
should  suffer  or  be  humiliated. 


296  OPERATION    OF   THE    HOSPITAL 

Relation  of  Interns  to  Visiting  Physicians. — Visiting  physicians  are  charged 
with  the  treatment  and  care  of  patients,  and  their  orders  should  be  conscientiously 
and  as  literally  carried  out  as  each  case  will  permit,  and,  if  the  interns  are  directly 
answerable  to  the  physicians  whom  they  are  serving  in  the  institution  in  all  pro- 
fessional matters,  the  largest  possible  measure  of  good  to  the  patient  will  be  the 
result. 

Rules  for  interns  must  explicitly  state  that  they  are  to  keep  in  constant  touch 
with  the  men  whose  patients  they  are  watching;  that  any  radical  or  alarming  change 
must  be  immediately  reported  to  the  attending  physician,  and  any  question  bear- 
ing upon  the  condition  of  the  patient  must  be  reported  to  the  attending  man  at  the 
first  opportunity,  whether  that  question  concerns  the  actual  physical  condition, 
medication,  or  dressing  of  the  patient,  or  whether  it  be  a  social  question  concern- 
ing the  patient's  relation  to  his  family  or  friends  or  to  the  hospital.  When  a  patient 
dies  during  the  absence  of  the  attending  physician,  the  intern  should  immediately 
communicate  the  fact  to  his  senior,  for  the  purpose  of  getting  orders  as  to  the  signing 
of  the  death  certificate,  or  whether  a  certificate  shall  be  signed,  and  whether  the 
physician  desires  to  sign  it  himself  or  requires  that  his  intern  shall  do.  so. 

The  interns  in  the  hospital  should  make  every  endeavor  to  prepare  the  cases 
for  visiting  physicians,  and  to  anticipate  their  wishes  in  regard  to  laboratory  or 
blood  work  that  ought  to  be  done.  The  intern  should  see  that  the  histories  are 
properly  written,  and  that  the  greatest  possible  amount  of  information  is  at  hand 
for  the  first  visit  of  the  attending  physician,  in  order  to  minimize  the  labor  of 
that  busy  man. 

The  relationship  between  the  intern  and  his  senior,  the  visiting  physician, 
should  not  be  wholly  one-sided.  There  are  obligations  on  both  sides.  The  young 
man  is  serving  his  internship  for  the  purpose  of  learning  the  greatest  possible 
amount  about  the  practice  of  his  profession,  and  it  is  the  duty  of  the  attending 
physician  to  help  him  in  every  way.  The  most  successful  visiting  physicians  in 
getting  work  out  of  the  members  of  the  house  staff  are  those  who  are  courteous  and 
considerate  toward  the  young  men.  This  does  not  mean  obsequiousness;  it  means 
merely  that  these  young  men  stand  in  the  relationship  of  a  junior  and  assistant,  a 
professional  apprentice  to  the  older  and  more  experienced  visiting  physician,  and 
they  ought  to  have  the  benefit  of  every  aid  that  he  can  give  them.  Unfortunately, 
some  visiting  physicians  demand  the  respect  of  the  members  of  the  house  staff; 
instead,  they  should  command  it.  They  should  deserve  it  by  their  conduct  toward 
their  patients,  toward  the  nurses,  toward  the  hospital  officials,  and  toward  the 
young  men  themselves.  In  the  experience  of  the  oldest  and  maturest  hospital 
superintendents  there  comes  rarely  an  incident  of  insubordination  to  authority  on 
the  part  of  interns  that  there  is  not  some  justice  on  both  sides,  and  too  often 
the  justice  is  far  more  on  the  side  of  the  hospital  intern  than  upon  that  of  his 
senior.  Perhaps  one  reason  for  this  is  that  visiting  physicians  are  busy,  tired  men. 
The  interns  are  sometimes  ignorant,  the  visiting  physicians  impatient  and  intol- 
erant of  ignorance,  and  it  has  been  very  often  known  to  happen  that  interns  have 
lost  their  respect  for  a  senior  wholly  because  of  the  latter's  inattention  to  his  duty, 
his  neglect  of  his  patients,  and  his  failure  to  perform  a  high  order  of  professional 
service,  and  these  young  men  are  quick  to  grasp  such  failure. 

The  relations  between  the  visiting  physicians  and  the  members  of  the  house 
staff,  and  the  obligations  of  each  toward  the  other,  need  in  no  way  affect  the  relations 
of  each  toward  the  superintendent  of  the  hospital.  When  a  visiting  physician  finds 
carelessness  or  neglect,  or  a  failure  to  perform  a  manifest  duty  on  the  part  of  the 
intern,  there  is  no  good  reason  why  he  should  not  censure  his  junior  with  becoming 


mil  Si:   MEDICAL  STAFF  207 

dignity,  which  need  never,  and  which  should  never,  go  to  the  extreme  of  abuse  or 
offensiveness  of  maimer  or  language.  If  the  offense  mi  the  pari  of  the  young  man 
is  severe  enough  to  justify  that  course,  it  should  lie  the  duty  of  the  attending  phy- 
sician to  bring  the  incident  to  the  attention  of  the  superintendent  of  the  hospital, 
who,  after  all,  must  lie  responsible  for  the  conduct  of  these  young  men,  and  in  whose 
discretion  should  he  left  whatever  action  is  necessary  in  the  case.  Too  often  visit- 
ing physicians,  fearing  some  retaliatory  act  on  the  pad  of  the  intern,  will  complain 
to  the  superintendent  of  the  hospital,  but  will  make  the  proviso  that  nothing  -hall 
be  done  in  this  particular  case  because  the  informer  desires  not  to  incur  his  junior's 
enmity.  This  course  of  conduct  is  hardly  fair.  Perhaps  the  intern  has  not  been 
at  fault  at  all,  perhaps  the  visiting  physician  misunderstands  the  attitude  of  the 
intern  in  the  case,  and  perhaps  from  sheer  embarrassment  the  intern  has  failed 
to  set  his  position  correctly  before  his  senior;  it  would  seem,  therefore,  the  duty 
of  the  superintendent  of  the  institution  to  insist  upon  an  immediate  reckoning  of 
the  case,  without  fear  that  the  feelings  either  of  the  attending  physician  or  the 
intern  may  be  hurt.  Such  an  outspoken  course  promises  a  clearing  of  the  atmos- 
phere, and  oftentimes  a  return  to  the  friendliest  feelings  between  the  two  gentle- 
men, who,  after  all,  must  work  together  if  there  is  to  be  a  high  order  of  service  and 
what  may  be  called  team  work. 

Relation  of  House  Medical  Staff  to  the  Nurses. — A  discussion  of  the  relation- 
ships that  exist  between  the  young  medical  men  of  the  institution  and  the  nurses 
is  an  approach  toward  very  delicate  ground.  It  may  not  be  hoped  that  any  atti- 
tude assumed  on  this  question  will  be  free  from  censure,  or  accepted  as  final,  by  any 
considerable  number  of  people  involved  in  this  relationship.  Perhaps,  then,  the 
most  important  feature  of  this  relationship  involves  the  broadness  or  the  narrow- 
ness of  those  who  are  responsible  for  the  actions  and  conduct  of  the  young  people 
of  both  sexes.  Generally  speaking,  the  young  medical  men  of  an  institution  will 
just  about  measure  up  to  the  opinion  of  their  seniors.  If  the  attitude  of  the  board 
of  directors  and  the  visiting  staff,  the  superintendent  of  the  institution,  and  the 
head  of  the  training-school  is  one  calling  for  the  highest  honor  and  the  most  gentle- 
manly bearing  of  these  young  men  toward  the  young  women  with  whom  they  must 
daily  come  in  contact,  it  might  be  taken  almost  for  granted  that  the  young  men  will 
live  up  to  this  good  opinion,  and  this  rather  complacent  attitude  as  to  their  moral 
tone.  If,  on  the  other  hand,  those  over  them  assume  that  these  young  gentlemen 
arc  reprobates  and  dishonorable,  and  that  they  must  be  watched  carefully  to  see 
that  they  do  not  commit  all  the  indiscretions  and  crimes  possible,  it  is  more  than 
likely  that  the  attitude  of  the  young  men  will  be  one  in  which  trials  of  wit  and  daring 
will  be  the  chief  feature.  They  are  put  upon  their  mettle,  they  arc  distrusted,  they 
have  a  bad  name,  and  are  more  than  likely  to  try  to  deserve  it. 

In  many  institutions  there  is  a  hard-and-fast  rule  that  interns  ami  nurses  are 
not  allowed  to  speak  to  each  other  except  while  on  duty,  and  then  only  concerning 
work  in  hand.  There  are  other  institutions  in  which  nurses  and  interns  arc  dis- 
missed from  the  institution  for  having  any  sort  of  social  relationship,  such  as  an 
evening  walk  together,  or  a  chat  in  some  quiet  part  of  the  grounds  of  a  summer 
evening. 

On  the  other  hand,  there  are  institutions  in  which  parties  are  given  to  the 
young  people,  and  during  which  they  are  allowed  to  dance  with  each  other  and  have 
a  good  social  evening  of  it.  Not  long  since  in  a  certain  large  institution  such  an 
arrangement  as  this  began.  The  nurses  were  given  a  party  each  month,  and  the 
interns  were  always  expected.  Before  the  first  party  was  undertaken  there  was  a 
heart-to-heart   talk  with    the   nurses   and  with   the  interns,   in  which   the  epoch  of 


298  OPERATION    OF   THE    HOSPITAL 

'  parties  and  evening  entertainments  was  promised,  only  on  the  condition  that  the 
entertainments  would  continue  just  so  long  as  the  young  people  appreciated  them 
to  an  extent  that  would  not  allow  them  to  interfere  in  any  way  with  their  respective 
duties  in  the  institution;  that  if  it  became  necessary  for  the  young  people  to  chat 
about  "last  night"  during  their  work  in  the  institution  the  next  morning,  and  to 
live  the  evening's  entertainment  all  over  again  when  their  duties  were  elsewhere,  then 
the  parties  would  cease  and  never  again  be  commenced.  The  evening  entertain- 
ments in  this  institution  have  never  been  interrupted  since  that  time,  and  there 
never  has  transpired  a  single  incident  in  the  conduct  or  actions  of  either  interns 
or  nurses  that  could  give  rise  to  a  feeling  on  the  part  of  their  superiors  in  the  hos- 
pital that  these  entertainments  were  unwise. 

In  this  same  institution  the  nurses  and  interns  are  allowed  to  walk  out  together 
when  not  on  duty.  They  may  sit  together  in  the  grounds  and  on  the  steps  and  en- 
joy short  periods  of  comradeship,  and  if  an  eavesdropper  could  hear  the  conversation 
during  these  resting  spells,  he  would  oftener  than  not  find  that  it  drifted  toward  the 
duties  of  the  day,  a  recitation  of  the  trials  and  triumphs  in  the  sick  ward.  If  once 
in  a  long  while  Cupid  should  chance  to  perch  himself  upon  the  back  of  a  bench  be- 
tween one  of  these  young  couples,  the  eavesdropper  would  find  that  the  Cupid 
was  an  honest  youngster,  free  from  guile,  and  that  he  was  shooting  an  honest  dart, 
and  if  the  eavesdropper  remained  until  he  had  seen  love's  arrow  pierce  the  hearts 
of  the  young  wooers,  he  would  hear  their  conversation  bent  upon  the  future,  with 
perhaps  a  recitation  of  the  hopes  and  the  fears  of  an  honest  union  as  the  two  should 
walk  together  down  life's  busy  way. 

So  that  it  would  seem  the  relationship  between  the  young  people  and  their 
seniors,  and  the  conduct  of  these  young  people  toward  each  other,  can  be  regulated 
almost  at  will  by  the  seniors,  without  in  any  way  limiting  the  freedom  of  intercourse 
of  the  young  people. 

Relation  of  the  House  Medical  Staff  Toward  Patients. — It  has  been  truthfully 
said  that  the  worst  place  for  a  young  medical  man  to  begin  his  career  is  in  one  of 
the  large  charity  institutions  of  the  country  where  the  poor  are  called  "paupers," 
and  where  the  sick  are  regarded  as  mere  "cases"  and  as  so  much  "material."  In 
these  great  institutions  the  paid  officials  and  retainers  serve  over  long  periods  of 
time,  and  they  become  calloused  and  indifferent  to  suffering.  They  come  hourly 
in  contact  with  the  lowest  order  of  human  beings,  men  who  are  vicious,  ignorant,  and 
unappreciative,  and  women  who  are  worse,  and  it  is  into  such  an  atmosphere  that 
these  young  people  are  thrown  without  the  experiences  of  life  behind  them.  Is  it 
any  wonder  that  they  accept  the  attitude  of  those  about  them,  and  assume  the  same 
manner  toward  the  patients?  And,  if  such  is  the  atmosphere  that  pervades  the 
large  charitable  institutions  of  this  country,  there  is  a  far  worse  atmosphere  in  the 
great  hospitals  of  Europe,  where  there  are  practically  no  nurses  with  training  as 
such,  and  where,  in  almost  every  case  of  obscure  or  interesting  pathology,  there  is 
a  latent,  if  not  expressed,  hope  in  the  minds  of  the  professional  men  that  they  will 
eventually  have  the  pleasure  of  confirming  their  diagnosis  in-  the  postmortem 
room. 

Such  an  atmosphere  is  not  one  calculated  to  train  the  young  physician  in  human- 
itarianism,  in  courtesy,  in  delicacy  of  feeling  toward  those  who  are  suffering  and 
in  distress.  On  the  contrary,  the  best  atmosphere  within  which  these  young  gentle- 
men may  begin  their  professional  lives  with  the  greatest  possible  hope  of  return 
is  the  hospital  in  which  the  higher  requirements  of  studentship  are  exacted,  in 
which  the  patient  is  regarded  as  a  human  being,  in  which  humanitarianism  is  a 
confirmed  habit  of  thought,  and  in  which  the  free  patients  are  regarded  as  upon 


HOUSE    MEDICAL    STAFF  299 

exactly  the  same  level  as  those  who  pay  the  highest  fees  for  their  service.  Amid 
such  surroundings  as  these  the  young  medical  man  may  hope  to  have  his  sympathies 
aroused  rather  than  deadened.  He  may  hope  to  realize  a  state  of  mind  that  will 
make  his  profession  a  mission  of  mercy.  There  are  some  physicians  who  regard  it 
as  a  sacred  privilege,  almost,  to  be  with  their  patients  when  the  end  comes,  so  that 
they  may  console  and  sympathize  with  the  family,  and  perform  those  little,  trivial, 
but  important,  services  which,  if  they  do  not  render  death  less  terrible,  at  least  make 
it  more  bearable  to  those  who  survive. 

These  thoughts  are  the  structure  upon  which  successful  internship  should  be 
built;  a  young  man  in  the  hallowing  influences  of  a  humane,  sympathetic  environ- 
ment need  not  feel  that  his  conduct  toward  his  patients  in  after-life  will  be  anything 
but  proper;  his  bearing  could  not  well  be  coarse  or  brutal,  and  one  of  the  greatest 
satisfactions  that  can  come  to  the  high-minded  physician  is  a  feeling  that  his  people 
venerate  and  lean  upon  him  in  their  hours  of  suffering. 

In  the  institution  it  should  be  the  duty  of  the  interns  to  remain  on  their 
wards  at  all  regular  visiting  hours.  They  ought  to  be  there  for  the  purpose  of 
giving  information  to  the  friends  of  patients,  and  thus,  too,  they  will  learn  how  to 
conduct  themselves  with  the  friends  of  patients.  The  responsible  relatives  have 
a  right  to  know  the  condition  of  a  father,  mother,  or  sister,  and,  if  the  story  the 
intern  must  tell  is  a  sad  one,  he  will  soon  learn  how  to  tell  it  so  that  the  heavy 
blow  will  not  fall  too  suddenly  when  it  is  too  heavy  to  bear,  and  thus,  again,  he  will 
get  one  of  the  most  profitable  lessons  for  his  career  when  he  leaves  the  institution. 

It  is  in  the  attitude  of  the  intern  toward  the  private  patients  of  a  visiting 
physician  that  the  greatest  delicacy  will  be  required.  The  intern  is  not  the 
physician — he  merely  represents  the  physician  as  an  assistant,  and  his  bearing  in 
the  presence  of  his  senior  should  be  one  of  the  utmost  loyalty  and  one  of  perfect 
confidence.  Perhaps  he  may  have  misgivings  as  to  the  diagnosis  that  his  senior 
has  made,  the  course  of  the  disease,  and  the  treatment,  and  it  would  seem  that  he 
has  a  right  to  express  this  doubt  to  his  senior,  but  certainly  not  to  the  patient  or 
the  patient's  friends. 

Perhaps  this  pendulum  may  swing  too  far  the  other  way  with  some  young  men ; 
there  may  be  a  tendency  to  become  more  than  properly  intimate  with  the  patients 
of  the  visiting  physician;  they  may  arrogate  too  much  to  themselves  in  the  treat- 
ment and  care  of  the  patient,  and  thus  raise  a  doubt  in  the  mind  of  the  patient  or 
his  friends  as  to  whether,  after  all,  the  intern  is  not  the  better  doctor  of  the  two. 
This  has  been  known  to  occur.  Interns  should  be  quick,  courteous,  sympathetic, 
and,  above  all,  businesslike  in  their  dealings  with  the  private  patients  of  their 
seniors.  They  should  visit  the  sick  room  as  often  as  duty  calls  them.  They  should 
stay  while  it  is  their  duty  to  be  there,  and  they  should  immediately  leave  when  that 
duty  is  accomplished.  It  is  no  part  of  the  duty  of  an  intern  to  visit  a  patient  in  the 
hospital  socially,  to  sit  with  the  patient's  friends  and  relatives;  such  conduct  is 
disloyal  to  the  attending  physician,  and  no  honorable  intern  will  be  guilty  of  it. 

In  the  course  of  his  dealings  with  visiting  physicians  in  the  institution  the  intern 
will  have  occasion  sometimes  to  so  gravely  question  the  ability  of  his  senior  in  a 
given  case,  and  so  seriously  doubt  the  correctness  of  his  views  regarding  the  patient, 
that  it  will  be  his  duty  to  confide  his  doubts  and  misgivings  to  his  closest  superior, 
the  superintendent  of  the  institution,  who,  in  some  such  way  as  may  best  suit  the 
purpose,  will  ascertain  for  himself  the  correctness  or  incorrectness  of  the  young 
man's  judgment,  and  take  proper  action  to  safeguard  the  patient's  best  interests; 
but  these  misgivings  should  never  be  confided  to  another  visiting  physician  under 
any  circumstances  whatever,  and   the   wise  intern  will  never  discuss  the  conduct 


300  OPERATION    OF   THE    HOSPITAL 

of  one  physician  with  another.  These  men  are  on  competing  ground  in  the  hospital, 
their  interests  clash,  their  ideals  are  sometimes  sordid,  their  motives  sometimes  self- 
ish, and  one  may  never  know  when  a  casual  remark  of  an  intern,  suggesting  a 
weakness  or  failure  on  the  part  of  the  physician,  may  not  be  used  to  his  detriment 
by  another. 

Relation  of  Interns  toward  Each  Other. — An  esprit  du  corps  in  an  intern 
staff  is  a  guarantee  and  forerunner  of  successful  work;  the  want  of  it  stands  for 
failure.  These  young  men  have  not  always  the  best  judgment,  as  they  have  not 
had  broad  experiences  of  life,  and  too  often  they  may  feel  that  their  success  must 
be  purchased  at  the  expense  of  some  one  else  in  the  brotherhood.  The  contrary  is 
true.  Where  there  is  a  fine  spirit  of  comradeship  and  mutual  helpfulness  better 
work  will  be  done,  a  broader  education  will  be  attained,  and  a  worthier  maturity 
for  the  young  men  will  be  the  result.  The  intern  who  adds  one  atom  to  the  sum 
of  common  knowledge  helps  his  fellows  not  alone  by  the  one  idea  that  he  has  offered, 
but  the  mere  fact  of  his  keenness  has  put  his  fellows  upon  their  mettle  and  thus  sown 
the  seed  of  ambition  and  emulation,  and  a  full  harvest  of  achievement  will  result. 
■  On  the  other  hand,  if  there  is  a  selfish  secretiveness,  each  man  hiding  and  hold- 
ing what  he  gets,  no  one  helping  any  one  else,  there  will  breed  a  narrowness,  a  want 
of  progressiveness,  and  the  whole  corps  will  suffer.  Not  alone  will  a  broad  spirit 
of  helpfulness  in  the  corps  redound  to  the  credit  of  the  men  in  after  years  in  a 
greater  knowledge  of  the  science  of  medicine,  but  for  their  temporary  purposes; 
their  comforts  will  be  greater,  they  will  have  more  pleasure  in  their  work,  they  can 
relieve  each  other  for  recreation,  do  each  other's  work  on  occasion,  to  the  end  that 
the  whole  corps  may  have  a  freedom  of  action  that  will  allow  them  to  keep  outside 
engagements  freely,  because,  having  unselfishly  helped  an  intern  friend,  they  will 
be  free  to  call  upon  him  for  service  in  kind. 

By-products  of  Internship. — It  is  not  enough  that  young  men  shall  be  trained 
in  the  practical  essentials  of  their  profession  in  the  hospital;  that  they  shall  be  broad- 
ened and  ripened  in  the  humanities  and  started  upon  the  way  of  world  knowledge. 
It  is  equally  incumbent  on  the  hospital  to  drill  and  train  them  in  the  art  of  study, 
and  teach  them  how  to  meet  their  fellows  of  the  profession  on  the  rostrums  and  in  the 
pages  of  the  periodicals.  Medical  men  are  not  measured  wholly  by  what  they  know, 
but  by  what  they  can  tell  of  what  they  know.  Therefore  interns  should  be  taught 
to  search  the  literature,  to  prepare  papers  on  live  subjects,  and  to  read  those  papers 
and  be  prepared  to  defend  them  in  gatherings  of  physicians. 

An  excellent  way  to  do  this,  and  one  in  use  in  at  least  a  few  of  the  large  hos- 
pitals, is  to  organize  the  intern  corps  into  an  institution  clinical  society.  This  society 
should  meet  at  least  once  or  twice  a  month  on  regular  and  fixed  dates,  and  should  be 
conducted  by  some  medical  man  of  experience  connected  with  the  hospital,  prefer- 
ably the  director  of  the  laboratory  of  pathology.  This  permanent  president  should 
apportion  out  the  dates,  make  the  programs,  aid  in  the  preparation  of  the  papers, 
and  generally  act  as  mentor  of  the  corps.  Usually  the  visiting  staff  men  in  the 
different  services  will  be  able  to  suggest  pieces  of  original  work  for  their  interns, 
based  on  a  case  or  a  series  on  the  wards,  and  the  attending  physician  will  always 
be  glad  to  direct  the  search  of  the  literature  and  the  subsequent  preparation  of 
the  paper.  There  will  be  some  one  always  at  hand  on  the  medical  staff  who  will 
edit  the  paper  for  style  and  composition.  The  director  of  the  seminar  or  society 
should  personally  see  that  the  writer  has  covered  his  subject  in  a  way  that  will  make 
the  paper  a  credit  to  him  and  to  the  institution.  The  medical  journals  will  always 
be  glad  to  publish  such  papers  if  they  are  really  worth  while,  and  by  the  time  he 
has  finished  his  internship  each  member  of  the  corps  will  have  introduced  himself 


HOUSE   MEDICAL   STAFF  301 

in  the  literature  of  his  profession,  and  his  reprints  will  be  his  best  introduction  to  the 
medical  men  in  the  community  where  he  settles  down  to  practice. 

These  intern  meetings  can  be  made  so  popular  that  members  of  the  attending 
and  consulting  staffs  will  attend  them  and  take  part  in  the  discussions.  To  add  to 
the  interest,  each  meeting  may  be  started  with  a  demonstration  of  cases  from  the 
wards,  the  interns  presenting  them.  The  attending  men  of  the  services  will  always 
be  glad  to  lead  the  discussion  of  their  own  cases,  and  in  this  way  the  interns  are 
thrown  into  the  maelstrom  of  active  debate  with  their  seniors,  and  they  will  learn 
to  talk  extemporaneously  and  on  their  feet. 

In  Europe  it  is  the  practice  for  the  assistant  or  intern  to  sign  the  paper  for  publi- 
cation, and  to  credit  the  work  to  the  service  of  Professor  So-and-So  of  blank  clinic. 
If  this  is  done,  the  head  of  the  service  is  at  once  enlisted  in  behalf  of  the  paper,  and 
he  will  want  it  to  go  out  in  a  creditable  condition.  The  societies  benefit  the  hos- 
pital, the  patients,  the  attending  staff,  but,  above  all,  the  interns. 

Rules  for  Interns 

All  the  foregoing  discussion  upon  the  subject  of  interns  focuses  upon  a  few 
fundamental  rules  of  conduct.  A  set  of  these  rules  is  appended  as  seeming  to  meet 
the  necessities  for  almost  anv  occasion  in  intern  service: 


RULES  FOR   THE   HOUSE  STAFF 

1.  The  number  of  house  physicians  shall  be  fixed  by  the  board  of  directors,  and  may  be 
changed  from  time  to  time  as  the  exigencies  of  the  service  may  require. 

2.  The  term  of  service  for  members  of  the  house  staff  shall  be  two  years,  but  the  board  of 
directors  may  terminate  the  service  of  any  member  at  any  time,  either  because  of  any  delin- 
quency on  the  part  of  said  member  or  in  the  interest  of  the  service  of  the  hospital. 

3.  Members  of  the  house  staff  shall  be  chosen  each  year  by  competitive  examination,  the 
details  of  such  examination  and  the  eligibility  of  candidates  to  be  fixed  arbitrarily  by  the  board 
of  directors. 

4.  Before  entering  upon  their  duties,  each  member  of  the  staff  shall  subscribe  to  the  fol- 
lowing obligation:  "This  is  to  certify  that  I  accept  the  position  of  member  of  the  house  medical 

staff  of  the Hospital,  that  I  have  carefully  read  the  rules 

and  regulations  of  said  hospital,  and  that  I  will  carefully  abide  by  them  and  by  any  other  rules 
and  regulations  properly  authorized  during  my  term  of  service." 

5.  Members  of  the  house  staff  shall  be  divided  into  juniors  and  seniors,  serving  one  year 
in  each  capacity,  unless  otherwise  assigned  by  the  board  of  directors  or  the  superintendent  of  the 
hospital. 

6.  At  the  close  of  their  service,  if  the  same  has  been  satisfactory  to  the  board  of  directors, 
each  member  of  the  staff  shall  be  awarded  a  diploma,  signed  by  all  the  officers  of  the  board  of 
directors,  by  the  members  of  the  staff  committee  of  the  board,  and  by  all  the  members  of  the 
conference  committee  of  the  medical  staff. 

7.  Duties  of  Juniors. — During  their  junior  year  members  of  the  house  staff  shall  be  under 
the  immediate  direction  of  the  senior  in  the  particular  service  in  which  they  are  engaged,  and  shall 
further  specifically  perform  the  following  duties:  (a)  Take  and  record  minutely  and  carefully 
the  history  of  each  patient  as  soon  after  his  or  her  admission  to  the  hospital  as  the  exigencies  of 
the  case  will  permit,  but,  in  any  case,  within  twelve  hours  after  admission;  (6)  personally  see  that 
all  data,  including  the  necessary  laboratory  findings,  are  obtained  for  the  information  of  the 
attending  man  in  the  case  at  the  earliest  moment  possible;  (c)  make  daily  additions  to  the  history 
of  each  case,  recording  any  new  developments,  as  indicated  by  the  attending  man  or  the  senior 
in  the  service,  and  describing  in  detail  any  operation  that  may  have  been  performed,  with  the  full 
names,  and,  where  possible,  the  addresses,  of  every  person  who  was  present  at  said  operation 
(excepting  the  nurses);  (<J)  he  shall  do  any  and  all  dressings  that  may  be  required  of  him  by  the 
attending  man  or  his  senior;  (c)  shall  accompany  on  the  rounds  of  (lie  hospital  such  attending 
men  as  may  require  such  service,  and  shall  note  on  the  record  sheets  of  each  patient  visited,  at  the 
time  of  the  visit,  such  orders  as  may  be  given  by  such  attending  men,  and  in  any  other  eases  re- 
quired of  him  by  the  superintendent  of  tin1  hospital. 

8.  Dulns  of  Si  niors. — Senior  members  of  the  house  staff  shall  be  responsible  for  the  exact 
carrying  out  of  all  orders  of  all  the  attending  men  in  the  service  in  which  they  are  engaged,  shall 
report  to  the  superintendent  of  the  hospital  any  negligence  or  deficiency  on  the  part  of  their 


302  OPERATION    OF   THE    HOSPITAL 

juniors  or  the  nurses  in  the  cases  under  their  charge,  and,  either  personally  or  by  their  juniors, 
shall  accompany  all  attending  men  on  their  rounds  of  the  hospital,  unless  such  attendance  is 
specifically  excused  by  the  attending  man  in  any  particular  case;  they  shall  assist  the  attending 
men  in  all  operations,  unless  specifically  excused  in  any  particular  case.  In  the  absence  of  the 
junior,  or  when  the  latter  is  properly  busy  with  other  work,  the  senior  will  personally  make  blood- 
counts  and  pressure,  establish  the  Widal,  make  urinalysis,  or  shall  see  that  such  data  are  furnished 
for  the  information  of  attending  men. 

9.  No  member  of  the  house  staff  shall  perform  any  surgical  operation  or  anesthetize  any 
patient,  except  in  the  presence  of  the  attending  man,  without  the  specific  consent  of  the  super- 
intendent of  the  hospital. 

10.  Members  of  the  house  staff  shall  be  in  their  wards  during  visiting  hours,  from  2  to  4 
on  Wednesdays  and  Sundays,  for  the  purpose  of  protecting  patients  from  undue  annoyance  on 
the  part  of  visitors,  to  answer  such  reasonable  questions  as  may  be  put  to  them  by  anxious  rela- 
tives and  friends  of  patients,  and  to  assist  in  the  preservation  of  order  and  decorum  in  the  hospi- 
tal. This  duty  shall  be  mandatory  during  the  whole  visiting  times  specified,  unless  specifically 
excused  by  the  superintendent  of  the  hospital. 

11.  Each  member  of  the  house  staff  may  be  absent  from  the  hospital  one  afternoon  and  one 
evening  each  week,  the  afternoon  hours  to  run  from  1  to  6  o'clock  and  the  evening  hours  from 
6  to  12,  afternoons  and  evenings  to  be  fixed  by  the  superintendent  from  time  to  time,  as  the 
exigencies  of  the  service  may  require;  provided,  that  no  member  may  exercise  the  privilege  of 
absence  under  this  clause  at  any  time  when  he  has  a  dangerously  sick  patient  under  his  care,  or 
an  impending  abnormal  obstetric  case,  without  the  express  consent  of  the  attending  man  in  such 
case,  or  the  consent  of  the  superintendent  of  the  hospital;  further  provided,  that  no  senior  and 
junior  in  any  one  service  shall  leave  the  hospital  premises  at  the  same  time  without  the  express 
consent  of  the  superintendent  of  the  hospital;  and  further  provided,  that  no  such  absences  will 
be  permitted  during  the  regular  visiting  hours  without  the  consent  of  the  superintendent.  Before 
absenting  himself,  each  member  shall  sign  "out"  in  the  book  kept  for  that  purpose  in  the  office 
of  the  superintendent,  writing  plainly,  and  in  its  proper  place  in  the  page,  the  precise  time  of  leav- 
ing, and  the  precise  time  he  expects  to  return;  where  possible,  a  telephone  number  must  be  given 
by  which  to  locate  the  member  in  case  of  an  emergency.  Upon  his  return  each  member  shall 
sign  "in"  with  the  precise  time  of  his  return,  in  the  space  provided  for  that  purpose;  but  he  will 
not  erase  any  previously  written  data. 

12.  Members  will  assist  in  every  way  to  preserve  silence,  order,  and  decorum  in  the  hospital; 
they  will  wear  rubber  heels  upon  their  shoes,  refrain  from  loud  talking  and  laughing;  and,  in  their 
own  quarters,  will  make  no  noise  that  will  penetrate  to  other  parts  of  the  hospital. 

13.  Members  of  the  staff  will  be  expected  to  observe  the  strictest  decorum  and  the  utmost 
courtesy  toward  the  nurses  in  the  service,  and  to  limit  their  relations  to  the  nurses  within  strictly 
professional  bounds;  any  deviation  from  this  rule  will  be  sufficient  for  instant  dismissal  from  the 
Institution.  They  shall  not  prescribe  any  medical  or  surgical  treatment  for  any  nurse,  except 
upon  the  express  request  of  the  superintendent  of  the  training-school. 

14.  Members  of  the  staff  will  bear  themselves  with  courtesy  toward  their  fellow-workers  in 
the  hospital,  and,  to  this  end,  will  address  all  attending  men,  the  superintendent  of  the  hospital, 
and  the  nurses  while,  standing,  and  will  continue  standing  unless  requested  to  be  seated  by  the 
person  with  whom  the  conversation  is  taking  place. 

15.  Members  of  the  staff  undertake  to  give  their  undivided  services  to  the 

Hospital  in  return  for  the  professional  experience  they  hope  to  acquire;  being  thereby 

fully  compensated,  they  shall  not  practice  their  profession  to  any  extent  whatever  except  for  the 
hospital,  and  shall  not  accept  any  fee  or  emolument  of  any  kind  for  such  services  from  any  one 
whatsoever,  either  directly  or  indirectly.  And,  under  no  circumstances,  will  a  member  of  the 
staff  perform  any  professional  service  for  an  attending  man  outside  the  hospital,  or  remove  any 
instrument  or  piece  of  apparatus  from  the  hospital  for  such  purpose,  without  the  specific  consent 
of  the  superintendent  in  each  case. 

16.  Members  of  the  staff  are  expected  to  keep  in  constant  touch  with  their  attending  men,  to 
take  all  their  orders  concerning  the  care  of  patients  from  them,  to  communicate  to  them  any  un- 
toward or  unexpected  development  in  any  case  at  once,  and  failing  to  find  such  attending  man 
or  men  shall  report  such  developments  at  once  to  the  superintendent  of  the  hospital.  Immedi- 
ately upon  the  death  of  a  patient,  the  senior  in  charge  of  the  service  in  which  such  death  occurs 
will  report  such  death,  in  person,  to  the  superintendent  of  the  hospital,  and  as  soon  thereafter  as 
possible  shall  communicate  the  facts  to  the  attending  man  in  the  case,  taking  his  orders  as  to  the 
signing  of  the  death  certificate  and  cause  of  death,  as  to  whether  it  is  the  desire  of  the  attending 
man  to  himself  sign  the  certificate,  or  direct  the  member  of  the  house  staff  to  do  so,  the  member  of 
the  house  staff  will  thereupon  proceed  immediately  to  carry  out  such  orders. 

17.  It  is  expressly  forbidden  for  any  member  of  the  staff  to  disclose  to  any  outsider,  or  for 
the  benefit  of  any  outsider,  any  part  of  the  record  or  history  of  any  patient  of  the  hospital,  past  or 
present,  or  to  discuss  any  such  patient's  case  with  any  outsider  whatsoever;  provided,  however, 
that  this  clause  will  not  prevent  any  member  of  the  staff  from  informing  any  relative  or  immediate 
friend  concerning  the  state  of  the  patient's  health,  the  likelihood  of  recovery,  or  the  reverse,  or 
to  prepare  such  friend  or  relative  for  impending  death. 

18.  Members  of  the  staff  shall  not  enter  the  private  rooms  of  the  hospital,  excepting  where 
they  are  in  specific  attendance  upon  the  occupant,  and  will,  under  no  circumstances,  discuss  the 


HOUSE    MEDICAL   STAFF  303 

diagnosis  or  prognosis  of  a  case,  either  with  the  patient  himself  or  with  a  friend  or  relative  of  any 

Crivate  patient,  except  upon  the  express  request  of  the  attending  man  in  the  case;  and  no  mem- 
er  of  the  staff  shall  hold  any  social  intercourse  with  any  patient  in  the  hospital  without  the  express 
consent  of  the  superintendent. 

19.  No  postmortem  examination  shall  be  held  in  the  hospital  except  upon  the  written  consent 
of  the  superintendent,  after  having  the  consent  of  the  nearest  relative,  and  in  any  case  when  any 
such  postmortem  is  performed  by  any  member  of  the  house  staff,  such  written  consent  of  the 
superintendent,  and  the  postmortem  findings  in  such  case,  shall  become  a  part  of  the  record  of 
such  case,  and  be  filed  with  such  record. 

20.  Any  violation  of  any  of  these  rules  will  be  sufficient  to  warrant  the  instant  dismissal  of 
the  offender. 


THE  MODERN  TRAINED  NURSE 

There  seems  to  be  something  radically  wrong  with  the  trained  nurse  of  to-day — 
the  medical  profession  says  there  is  something  wrong;  the  thinking  women  at  the 
head  of  training-schools  say  there  is  something  wrong;  and  the  lay  public  finds 
something  radically  wrong.  Not  all  of  these  elements  agree  as  to  just  what  the 
trouble  is,  in  fact,  they  all  seem  to  differ. 

The  doctors  say  the  nurses  who  are  being  graduated  from  the  training-schools 
are  not  efficient,  and  a  great  many  thinking  members  of  the  medical  profession  say 
that  the  nurses  are  being  trained  to  too  fine  a  point,  but  not  in  the  right  direction. 
The  heads  of  training-schools  think  the  nurses  are  not  being  sufficiently  trained. 
The  public  does  not  seem  to  care  to  analyze  the  situation,  but  merely  finds  fault 
with  the  nurse  as  an  individual. 

Let  us  see  if  we  cannot  agree  first  as  to  a  diagnosis  of  the  case,  and,  in  order  to 
do  so,  let  us  have  a  history,  so  to  speak. 

It  is  not  so  many  years  ago  since  there  were  no  women  nurses.  Up  to  a  cen- 
tury ago  nearly  all  nurses  were  members  of  the  religious  orders.  These  good  men 
and  women  presided  over  the  hospices  of  Europe,  and  took  the  best  care  they  knew 
how  of  the  sick  wherever  found.  At  a  later  day,  when  conditions  made  it  neces- 
sary for  the  people  to  create  independent  hospitals,  a  new  class  of  nurses  came  into 
existence — educated,  more  or  less  cultured,  kind-hearted,  but  erratic  men,  whose 
dissolute  habits  prevented  their  success  in  any  permanent  occupation,  and  who 
wandered  about  the  world  from  place  to  place,  nursing  the  sick  between  their 
periods  of  debauch.  These  men  acted  at  once  as  nurses  and  assistant  physicians. 
Many  of  them  were  graduated  medical  men,  expert  in  the  practice  of  their  profes- 
sion, and  one  here  and  there  occasionally  pulled  himself  together,  settled  into  a  well- 
ordered  life,  and  became  a  prominent  physician  in  the  locality  where  he  lived. 
The  few  women  nurses  of  that  day  were  of  the  Sairey  Gamp  order. 

The  Crimea  and  Florence  Nightingale,  and  not  long  afterward  the  American 
Civil  War  and  that  host  of  patriotic  women  who  went  upon  the  battlefields  to  nurse 
the  sick,  gave  an  impetus  to  the  profession  of  nursing  by  women.  It  became  a  fad 
for  young  women  of  culture  and  refinement  to  nurse  the  sick  in  the  slums  and  in 
the  hospitals  without  compensation;  and,  by  an  easy  evolution,  the  fad  of  nursing 
grew  into  a  definite  profession;  training-schools  were  organized,  and  young  women 
were  taught  how  to  nurse  the  sick  scientifically  and  efficiently. 

Nursing  in  that  early  day  was  not  what  it  has  come  to  be.  There  was  no 
pathology  worth  the  name.  Almost  nothing  was  known  about  the  chemic  and  phy- 
siologic constituents  of  the  blood,  the  urine,  the  various  excreta,  and  the  tissues 
of  the  body.  Much  medicine  was  used,  and  trained  nurses  were  taught  to  give  this 
medicine  intelligently,  to  feed  the  patient  with  what  the  doctor  ordered,  and  to  look 
after  his  personal  comfort.  These  things  were  enough  in  that  day,  because  they 
met  the  demands  of  the  medical  profession.  The  doctor  himself  knew  no  more. 
But  even  in  the  time  that  we  are  now  contemplating  the  work  of  the  women  nurses 
was  supplemented  by  a  considerable  amount  of  service  by  male  nurses,  especially 
in  surgery. 

304 


THE    MODERN   TRAINED    MUSK  305 

Then  came  antisepsis,  with  somewhat  technical  demands,  and,  following  the 
discoveries  of  Koch  and  Pasteur,  Billroth,  and  Virchow,  there  came  about  an  era 
of  pathology,  simple,  it  is  true,  as  practised  in  the  hospitals  and  at  the  bedside  of 
the  sick,  but  at  least  a  beginning.  As  this  technical  work  grew,  the  trained  nurse 
went  along  in  the  old  way,  participating  not  at  all  in  it,  and  there  came  a  time 
eventually  when  the  members  of  the  medical  profession,  finding  their  demands  not 
otherwise  met,  surrounded  themselves  in  the  hospitals  and  in  private  practice  with 
young  physicians  just  out  of  the  schools,  who  could  give  them  what  the  nurses 
could  not. 

This  survey  brings  us  clown  to  to-day,  when  the  hospitals  all  over  the  country 
are  getting  their  professional  technical  nursing  done  by  young  physicians  whom  we 
call  interns,  and  the  nurse  goes  about  her  business  in  the  old  way,  with  a  smatter- 
ing here  and  there  of  technical  knowledge,  which  usually  proves  the  old  axiom  that 
a  "little  learning  is  a  dangerous  thing." 

It  is  held  by  some  of  the  foremost  exponents  of  trained  nursing,  as  practised 
in  the  training-schools  of  to-day,  that  hospitals  are  not  maintained  as  places  in 
which  to  care  for  the  sick  and  to  cure  their  diseases,  but  places  in  which  to  train 
young  women  to  do  efficient  nursing  out  in  the  world  of  private  practice.  If  this 
is  true,  which  may  be  safely  questioned,  then  it  would  seem  that  the  duty  of  the 
trained  nurse  must  include  the  performance  of  at  least  the  simplest  forms  of  tech- 
nical work  that  the  doctor  of  to-day  requires,  such  as  the  taking  of  a  blood-count, 
the  making  of  a  urinalysis ;  but  no  nurse  does  this.  It  must  be  done  by  an  intern 
who  is  being  trained  to  do  these  things  for  his  senior,  and  who  later  must  do  them 
for  himself. 

Comparatively  little  medicine  is  given  to  the  sick  nowadays.  The  physical 
comforts  of  the  patient  require  so  little  of  the  time  of  the  nurse  who  is  taking  care 
of  him  that  it  would  seem  almost  as  though  her  office  is  coming  to  be  a  sinecure,  which 
will  not  be  tolerated  indefinitely,  and  a  new  adjustment  of  the  whole  situation  must 
come.  If  the  newly  graduated  medical  men  must  continue  to  perform  practically 
all  the  technical  service  for  patients,  then  an  attempt  is  being  made  to  teach  the 
trained  nurse  things  that  she  will  not  have  use  for,  and  she  must  relegate  herself 
to  a  far  simpler  office,  just  above  that  of  the  menial  or  maid  of  all  work.  If  she  is  to 
take  some  of  these  offices  off  the  hands  of  the  physician,  she  must  be  taught  to  do  the 
work  in  a  workmanlike  manner,  which  she  isn't  taught  to-day. 

Perhaps  another  adjustment  is  possible,  that  there  can  be  two  classes  of  nurses, 
one  made  up  of  young  women  of  education,  culture,  and  refinement,  whose  men- 
tal equipment  and  preliminary  education  will  make  it  possible  for  them  to  learn 
the  needful  things  of  their  calling;  and  the  other  class,  made  up  of  well-disposed 
young  women  of  excellent  intention  and  limited  education,  whose  curriculum  can 
be  limited  within  their  mental  possibilities,  and  that  will  enable  them  to  give  a  cer- 
tain amount  of  very  primitive  care  to  the  sick. 

If  this  radical  judgment  of  the  status  of  the  trained  nurse  of  to-day  is  not  actually 
conceded  by  those  well-informed  women  who  lead  the  thought  of  the  modern  train- 
ing-schools, at  least  it  is  tacitly  admitted  in  their  construction  of  the  modern  curric- 
ulum, which  not  one  pupil  in  a  hundred  in  the  training-schools  can  by  any  possibil- 
ity master.  The  builders  of  these  curricula  feel  within  themselves  that  the  train- 
ing-schools are  not  living  up  to  modern  demands,  and  they  are  attempting  to  correct 
this  fault  by  setting  up  courses  of  study  that  would  fill  the  want,  but  their  pupils 
cannot  measure  up  to  them. 

There  are  one  or  two  reasons  why  this  situation  exists  in  the  profession  of  nursing. 
The  chief  one  perhaps  is  the  tremendous  growth  in  the  humber  of  hospitals,  ami  the 

•2(1 


306  OPERATION   OF   THE    HOSPITAL 

£t.  ga^totom^'a  Suapital  ©rahwd  glm^a'  jnstitatijm, 

WEST    SMITHF1ELD,    LONDON,    E.C. 


(Telegraphic  Address— " RAHERE,  LONDON.") 
Telephone  No.  981  Holborn. 


Under  the  Management  of  the  Governors  of  St.  Bartholomew's  Hospital 


The  Institution  is  under  the  direct  supervision  of  the  Matron,  and  supplies  to  the  public,  on  the 
following  terms,  and  subject  to  the  undermentioned  regulations,  thoroughly  competent  Nurses  who  have 
trained  in  the  Wards  of  St.  Bartholomew's  Hospital,  viz. : — 

For  all  Medical  and  Surgical  cases,  except  those  mentioned  below. ...        £2     2     0  per  week. 

For  cases  in  which  Massage  is  done  by  the  Nurse     2  12     6         „ 

For  Alcoholic  and  Nervous  cases  requiring  special   application   or 

methods ...  2  12    6        „ 

For  cases   of    Scarlet   Fever,    Diphtheria,   Measles,   or  any    other 

infectious  or  contagious  disease  ...         ...         ...         ...         ...  2  12     6         „ 

NOTE. — After  attending  any  such  case,  the  Nurse  must  be  thoroughly 
disinfected  before  her  return  to  the  Institute,  and  will  not  be 
available  for  duty  during  the  incubation  period  of  the  disease  with 
which  she  has  been  in  contact.  A  charge  of  Half  Fee  will  be  made 
for  this  period. 

For  all  cases  outside  the  United  Kingdom  (unless  the  Nurse 
accompanies  the  patient  from  England,  when  the  fee  will  be  tbe 
same  as  if  the  patient  remained  in  England)     ...         ...         ...  3     3     0        „ 

For  attendance  on  Operation  for  one  day  or  part  of  a  day     ...         ...  110 

Note.— Nurses  sent  to  Operation  cases  will,  if  required,  be  provided  with 
a  Box  containing  the  necessary  sterilized  appliances,  &c,  for  which 
an  additional  charge  of  One  Guinea  will  be  made. 

In  addition  to  these  charges  the  Nurse  must  be  paid  her  travelling 
expenses,  and  an  allowance  of  3s.  a  week  for  washing,  and  if 
she  is  asked  not  to  dress  in  uniform,  an  additional  fee  of 
10s.  6d.  a  week  must  be  paid. 

The  foregoing  charges  are  made  for  each  week  that  the  Nurse  is  employed. 

constantly  growing  demand  for  trained  nurses  in  private  practice.  There  are  not 
enough  young  women  of  education  and  gentility  to  meet  this  demand,  and  conse- 
quently recruits  must  be  drafted  from  an  inferior  class  mentally,  and,  alas!  some- 
times morally.  Those  of  us  who  are  familiar  with  the  world  of  private  nursing  in 
the  homes  of  the  well-to-do  sick  are  quite  aware  of  how  far  the  average  nurse  falls 
short  of  meeting  the  expectations  of  her  employers  and  the  attending  physician, 


THE    MODERN    TRAINED    NURSE  307 

(Reverse  of  the  card). 

1.  On  the  Nurse's  engagement  a  week's  payment  must  be  made  in  advance,  and  during  the  time 
of  her  engagement  the  weekly  charges  for  her  services  will  be  considered  as  due  and  payable  at  the  end 
of  each  successive  fortnight  after  the  first  week. 

2.  The  Nurse's  fees  must  be  paid  direct  to  the  Sister  of  the  Institution. 

3.  No  one  may  retain  a  Nurse  for  a  longer  period  than  two  months  without  the  special  permission 
of  the  Matron.  The  Matron  is  at  liberty  to  withdraw  or  change  a  Nurse  at  any  time  if  she  should  deem 
it  expedient  to  do  so. 

4.  It  is  requested  that  at  least  twenty-four  hours'  notice  of  the  intended  return  of  a  Nurse 
may  be  made  by  letter  to  the  Sister  at  the  Institute,  and  that  if  the  Nurse  is  at  a  distance  from  London, 
she  may  be  allowed  to  return  by  an  early  train. 

5.  Nurses  are  strictly  enjoined  to  carry  out  most  carefully  the  instructions  of  the  Medical 
attendant,  to  attend  to  the  wants  of  their  patients,  to  perform  any  office  that  the  nature  of  the  case 
may  require,  to  see  that  everything  is  clean  for  the  patient's  use,  and  to  keep  the  sick-room  neat  and 
properly  ventilated  ;  but  they  are  not  to  be  required  to  do  the  work  of  house  servants. 

6.  Nurses  are  also  enjoined  to  hold  sacred  the  knowledge  they  obtain  of  the  private  affairs  of  the 
family  in  which  they  are  engaged,  and  to  adapt  themselves  as  far  as  possible  to  the  usages  of  the  family. 

7.  It  is  particularly  requested  that  in  order  to  ensure  the  efficient  performance  of  her  duties, 
every  Nurse  be  allowed  to  have,  in  the  course  of  each  twenty-four  hours,  at  least  seven  consecutive  hours' 
rest  out  of  the  sick-room  ;  also  that  it  be  arranged  for  her  not  to  take  her  meals  in  the  sick-room  or  with 
the  servants,  and  that  she  be  allowed  to  have  daily  at  least  one  hour's  outdoor  exercise. 

8.  If  the  condition  of  the  patient  will  permit  of  the  Nurse's  absence,  she  should  be  allowed  to 
attend  Divine  Service  once  every  Sunday. 

9.  The  Nurse  may  not  be  sent  to  sleep  out  of  the  house  where  she  is  nursing  except  by  the 
permission  of  the  Sister. 

10.  Nurses  mnst  wear  their  uniform  indoors  during  the  whole  time  of  their  attendance  on  a  case, 
unless  other  arrangements  are  made  with  the  Sister. 

N.B. — Under  special  circumstances,  and  by  previous  arrangement  with  the  Sister  of  the 
Institution,  half-fees  may  bo  charged  for  any  part  of  a  week  not  exceeding  three  days  ;  for  any  time 
beyond  three  days,  full  fees  must  be  paid. 

and  the  heads  of  the  training-schools  are  constantly  annoyed  by  serious  complaints 
from  private  homes  that  the  members  of  their  alumna-  are  not  satisfactory  as 
nurses.  Perhaps  at  least  a  partial  cure  for  the  unsatisfactory  situation  in  the  pro- 
fession of  private  graduate  nursing  is  due  to  the  fact  that  the  training-schools  and 
the  alumnae  associations  have  no   control  or  disciplinary  power  over  their  mem- 


308  OPERATION    OF   THE    HOSPITAL 

bers.  England  has  a  lesson  for  us  in  this  regard.  Over  there  graduate  private 
nurses  are  attached  to  the  hospitals,  and  a  physician  wishing  to  employ  a  private 
nurse  must  telephone  to  the  hospital  for  her — make  all  of  his  arrangements  with 
the  hospital — he  must  pay  the  hospital  for  her  services  at  rates  printed  on  a  regular 
rate  card,  a  card  which  states  specifically  what  the  charges  are  for,  and  the  hospi- 
tals, under  these  conditions,  undertake  to  satisfy  the  physician  as  to  the  capa- 
bility of  the  nurse  they  send  him.  Individuals  among  the  lay  public  who  have  had 
to  employ  nurses  in  the  large  English  cities  report  what  is  evidently  a  much  better 
situation  over  there  than  on  our  side  of  the  water.  This  card  is  a  most  interesting 
exhibit  just  now,  and  is  reproduced  on  pages  306  and  307. 

This  much  cannot  be  said  of  the  nurses  on  the  Continent,  and  we  have  nothing 
to  learn  of  value  from  any  of  the  continental  countries  in  this  respect. 

If  there  is  any  question  about  the  justice  of  these  criticisms,  let  the  inquirer 
undertake  to  find  a  trained  nurse  from  any  school  who  knows  the  first  principles 
of  a  hospital  dietary,  or  who  can  tell  the  most  elementary  facts  about  infant  feed- 
ing and  milk  formulation,  excepting  in  the  same  way  that  the  nursery  maid  knows 
these  things;  or  who  has  the  slightest  knowledge  of  hydro-  or  electro-  or  physio- 
therapeutics, or  who  can  make  a  urine  examination  that  a  modern  physician  will 
accept,  or  a  blood-count  or  a  hemoglobin  determination,  or  take  a  blood-pressure. 
And  yet  the  curriculum  of  the  smallest  and  most  inconsequential  training-school  in 
the  land  advertises  these  subjects  as  a  part  of  its  course  of  study. 

All  these  forethoughts  are  so  self-evident,  and  they  are  so  familiar  to  the  pro- 
gressive members  of  the  medical  profession,  that  it  would  seem  almost  redundancy 
of  language  to  prosecute  this  phase  of  the  subject  further,  excepting  to  merely  insist 
that  what  has  been  said  here  is  not  in  the  spirit  of  unfriendly  arraignment,  but  rather 
for  the  purpose  of  calling  attention  to  glaring  deficiencies  in  hope  of  improved  con- 
ditions. And  this  brings  us  back  again  to  the  thought  that  perhaps  the  near  future 
may  develop  a  necessity  for  two  grades  of  graduate  trained  nurses,  just  as  there  are 
to-day  the  graduate  nurse  and  the  so-called  "practical"  nurse.  If  that  day  shall 
dawn,  the  humbler,  less  highly  educated  girl  will  be  trained  to  care  for  those  cases 
of  illness  that  do  not  require  much  technical  nursing,  but  rather  conscientious  ad- 
herence to  the  simple  orders  of  the  doctor,  while  her  more  gifted  or  better  educated 
sister  is  trained  to  a  higher  degree  of  efficiency  for  the  performance  of  a  good  many 
of  the  technical  services  that  now  fall  to  the  hospital  intern  and  the  busy  practi- 
tioner's young  medical  assistant.  The  signs  of  the  times  would  seem  to  point 
rather  this  way,  because  young  medical  men,  every  year  and  in  all  the  schools,  are 
being  taken  further  and  deeper  into  the  mysteries  of  the  microscope  and  into  the 
fields  of  empiricism,  leaving  them  less  and  less  time  to  perform  duties  that  after  a 
few  weeks  of  their  doing  become  mere  routine  drudgery.  It  may  be  argued  that 
if  there  are  young  women  who  have  a  capacity  to  receive  a  training  that  will  enable 
them  to  take  over  what  are  to-day  the  duties  of  the  intern,  why  are  they  not  fully 
equipped  to  go  a  step  further,  and  enter  full  fledged  into  the  medical  profession? 
Some  of  them  will  enter  there;  but  it  must  be  remembered  that  medicine  is  growing 
harder  all  the  time,  not  merely  on  its  mental  side,  but  from  a  physical  standpoint 
as  well,  and  it  must  be  already  noted  that  more  young  men  each  year  are  finding 
the  pace  too  fast,  and  are  dropping  out  before  the  preliminary  test  of  the  school  is 
accomplished.  How  will  it  be  then  with  young  women — not  the  isolated  case  of 
one  here  and  there,  but  with  a  class  sufficiently  large  to  make  an  impression  on  the 
times?  And  it  may  be  hoped,  in  the  interest  of  society,  that  no  considerable 
number  of  young  women,  at  this  necessarily  early  period  of  their  lives,  will  pre- 
meditatedly  forswear  the  eternal  law,  and  assume  obligations  that  will  require 


THE   MODERN   TRAINED    MUSK  309 

many  years  (if  arduous  intellectual  toil  to  accomplish,  to  the  utter  casting  away  of 
the  woman's  God-given  destiny. 

If  the  day  shall  dawn  when  nurses  can  tie  divided  into  two  classes  by  reason  of 
their  fundamental  differences  in  preliminary  training,  that  is,  primary  educa- 
tion, it  would  seem  not  a  very  difficult  task  to  fit  the  less  highly  educated  girl  for 
the  office  of  nurse  for  the  patient  who  needs  only  the  ordinary  creature  comforts, 
kindly  ministration  to  his  or  her  physical  wants,  and  conscientiousness  in  the 
carrying  out  of  the  doctor's  orders,  and  to  fit  the  more  highly  trained  young  woman 
to  be  the  assistant  to  the  doctor  in  the  more  exacting  cases  where  technical  skill 
is  required,  to  fill  the  many  teaching  positions  in  the  training-schools  and  hospitals 
that  are  now  most  indifferently  filled,  and  to  take  the  superintending  of  the  hundreds 
of  small  hospitals  now  operating  and  the  thousands  that  must  be  built  and  operated 
in  the  near  future. 

To  one  versed  in  the  already  intricate  hospital  technic  of  the  day,  it  is  hardly 
conceivable  that  both  these  classes  of  nurses  can  be  trained  together  in  any  one 
school  or  hospital  for  obvious  reasons,  but  might  not  the  great  charity  and  public 
hospitals  undertake  to  train  the  practical  nurse;  and  the  more  expensively  con- 
ducted private  and  mixed  hospitals,  with  comfortable  endowments  behind  them 
and  a  higher  class  of  patients  for  their  patronage,  be  charged  with  the  training  of 
the  higher  order  of  nurses? 

Preliminary  Training  of  Nurses. — Let  us  leave  now  the  broader  question  of  what 
the  modern  nurse  ought  to  be,  and  what  she  must  be  if  she  is  to  succeed  in  the 
future,  and  discuss  briefly  the  requirements  of  the  candidate  for  admission  to  the 
average  training-school  under  the  scheme  of  education  practised  at  the  present 
time. 

Nearly  all  training-school  catalogues  and  the  literature  sent  to  candidates  calls 
for  a  high  school  education  or  its  equivalent  as  a  prerequisite  to  admission.  Almost 
no  training-school  in  this  country  actually  does  require  such  preliminary  train- 
ing; but  should  the  candidate,  in  filling  out  her  application  blank,  state  that  she 
has  had  a  high  school  or  normal  school  education,  she  is  accepted  almost  without 
further  examination.  It  makes  little  difference  whether  she  is  temperamentally 
fitted  to  be  a  nurse,  whether  she  has  that  rather  rare  commodity  among  young 
women,  good  common  sense;  whether  she  is  steady,  has  good  morals,  and  a 
clean  mind,  as  indicating  her  home  breeding.  Some  of  the  most  conscientious 
graduated  nurses  and  pupils  in  training  are  young  women  who  would  scorn  to  tell 
a  lie,  and  who  would  admit  frankly  a  mistake  if  they  made  one;  some  of  them  have 
hardly  a  grammar  school  education,  many  of  them  have  been  maids  and  family 
nurses  for  small  children  in  private  homes,  and  have  studied  their  primary  arith- 
metic, reader,  and  speller  after  the  children  were  in  bed  at  night,  and  have  thus 
prepared  themselves  for  reading  the  thermometer,  for  taking  the  temperature, 
pulse,  and  respiration  of  the  patient,  and  for  recording  these  upon  the  nursing 
sheets  of  the  institution  which  they  hope  to  enter.  If  the  status  of  the  nurse  is  to 
remain  where  it  is  now,  such  girls  as  these,  if  they  have  common  sense,  a  sense  of 
responsibility,  trustworthiness,  truthfulness,  and  honesty,  will  eventually  make 
far  more  capable  nurses  and  lie  far  more  useful  to  the  doctor  than  the  girl  who  has 
had  a  much  higher  training  in  the  schools  and  colleges,  who  cannot  be  relied  upon. 
who  has  not  good  common  sense,  and  who  is  irresponsible  in  her  own  attitude 
toward  the  serious  life  she  is  setting  out  upon. 

Age  and  Temperament  of  Applicant. — The  age  of  the  applicant  is  an  item  in 
which  it  may  be  suggested  we  have  gone  astray  somewhat.  Generally  speaking, 
the  catalogues  of  training-schools  announce  that  candidates  musl  !»■  from  twenty- 


310  OPERATION'    OF    THE    HOSPITAL 

one  to  thirty-five  years  of  age.  Are  not  these  ages  too  extreme  at  both  ends? 
Many  young  women  eighteen  years  of  age  are  plenty  old  enough  to  take  the  train- 
ing for  a  nurse.  The  discipline,  the  habits  of  application,  and  industry  inculcated 
in  the  training-school  are  quite  as  good,  it  would  seem,  as  any  other  school  for  a 
young  girl;  her  contact  with  life  under  conditions  imposing  restraint  is  good  for 
her ;  things  as  she  will  see  them  are  real,  and  not  what  they  seem  to  the  average  school 
girl.  She  faces  facts,  and  not  dreams.  She  sees  the  tragedies  of  life,  and  learns, 
in  object  lessons  in  the  wards  of  the  hospital,  how  many  of  these  tragedies  are  due 
to  human  weaknesses  and  indiscretions,  and  the  very  closeness  of  her  contact  with 
these  tragedies  will  be  an  inspiration  for  her  to  take  other  paths  in  her  life. 

If  she  is  a  happy,  gay-hearted  girl  there  are  many  of  the  comedies  of  life  in  the 
training-school  and  not  a  few  of  the  sunshiny  spots.  She  associates  with  girls  of 
her  own  age,  most  of  them  serious,  wholesome-minded  young  women,  else  they  would 
not  have  sought  admission  to  so  serious  a  profession.  She  has  plenty  of  time  for 
wholesome  recreation;  in  a  word,  the  pupil  in  the  training-school  of  a  hospital 
sees  the  world  at  its  best  and  at  its  worst.  If  the  girl  of  eighteen  finds  at  the  close 
of  her  course  of  study  that  she  does  not  want  to  nurse,  and  thinks  she  is  better 
fitted  for  a  wife  and  mother,  then  who  shall  complain?  She  has  given  three  years 
of  good  honest  work,  efficient  and  valuable,  in  exchange  for  a  good  education. 
She  owes  no  one,  she  has  earned  it,  and  her  husband  and  her  children  will  be  the 
better  for  her  having  received  it.  So  let  us  set  back  the  age  at  which  girls  may  enter 
a  training-school,  set  it  back  as  far  as  the  character  of  the  girl  will  permit.  And 
perhaps  we  may  compromise  with  those  who  survey  the  whole  problem  of  nursing 
from  another  attitude  than  that  assumed  in  this  section,  by  proposing  that  we 
take  these  young  girls  and  give  them  a  year  of  preliminary  education,  an  educa- 
tion that  will  lead  them  toward  the  goal  intended,  without  introducing  them  at  all 
to  the  wards  of  the  hospital,  leaving  two  or  more  years  for  the  practical  training  of 
a  nurse,  just  as  the  universities  are  giving  to  young  men  and  young  women  some 
years  of  preliminary  training  that  lead  toward  a  profession  or  science,  without 
taking  them  into  the  holy  of  holies  of  that  science,  so  to  speak,  and  thus  leave  them 
the  option  to  set  a  new  course,  if  they  so  desire,  without  having  missed  a  compre- 
hensive education  for  other  walks  in  life.  Boston  does  this  to-day,  giving  an  elect- 
ive course  to  high  school  girls  to  fit  them  for  entrance  to  the  foremost  training- 
schools. 

Now  let  us  go  to  the  other  extreme — thirty-five  years.  It  may  be  doubted 
if  there  is  a  woman  in  the  world  who  arrives  at  the  age  of  thirty-five  years,  who  is 
yet  sufficiently  supple  minded  to  take  the  discipline  and  self-discipline  of  a  train- 
ing-school profitably,  whose  mental  make-up  is  yet  so  elastic  that  she  can  accommo- 
date herself  to  an  environment  radically  changed  from  the  course  of  her  previous 
life.  Ninety-nine  times  out  of  one  hundred  the  woman  over  thirty  who  applies 
for  admission  to  the  training-school  does  so  because  of  social  or  domestic  disap- 
pointments, and  who  shall  say  in  what  proportion  of  this  total  number  these  dis- 
appointments have  served  to  sweeten,  instead  of  souring,  the  life  and  character? 
To  such  women  the  training-school  is  merely  a  choice  of  evils.  Many  of  them  are 
nervous  and  under  the  exactions  of  the  training-school  become  more  nervous; 
and  another  great  number  are  women  whose  lives  have  been  misdirected,  and  who 
fall  into  the  new  place  with  a  protest  on  their  lips  and  in  their  hearts.  Is  it  pos- 
sible for  a  woman  like  this  to  give  charitable  care  and  attention  to  a  sick  child,  a 
sick  woman,  or  a  sick  man? 

We  see  so  few  women  past  thirty  who  began  the  career  of  a  trained  nurse,  and 
who  fell  in  with  the  life  successfully,  that  we  are  constrained  almost  to  take  the 


THE   MODERN   TRAINED   NURSE  311 

broad  ground  that  women  over  thirty  are  unfit  for  admission  to  a  training-school. 
Of  course,  it.  goes  without  saying  that  married  women — divorced  or  separated  from 
their  husbands,  with  perhaps  divorce  in  the  background — are  not  proper  proba- 
tioners for  a  training-school.  They  are  self-centered;  their  interests  are  elsewhere; 
in  their  own  minds  at  least  they  have  been  abused,  and  they  are  unable  to  devote 
themselves  to  others  to  the  exclusion  of  their  personal  affairs. 

In  rare  cases  the  widow,  if  she  be  young,  may  become  a  good  trained  nurse,  but 
not  very  often.  As  a  rule,  she  is  too  self-centered,  her  heart  is  in  the  past,  and  her 
hopes  and  ambitions  are  in  the  future,  and  one  will  rarely  find  a  widow  of  few  enough 
years  to  be  considered  eligible  for  a  training-school  who  has  actually  determined  to 
cast  aside  the  domestic  life;  but  in  this,  as  in  the  case  of  nearly  every  girl  who  applies 
for  admission  to  a  training-school,  the  exceptional  girl  is  the  one  who  will  make  the 
best  nurse.  So  that  no  hard  or  fixed  rule  can  be  made,  and  the  individual  herself 
must  be  chosen  for  what  she  is  and  not  for  her  class. 

Health  of  the  Applicant. — It  is  needless  to  say  that  good  health  is  one  of  the 
chief  assets  of  the  nurse.  No  one  who  is  sick  can  efficiently,  patiently,  and  success- 
fully take  care  of  another  person  who  is  sick,  and  it  must  be  remembered  that 
these  girls,  when  they  are  admitted  to  the  training-school,  are  launched  upon  a  three 
years'  apprenticeship,  and  every  safeguard  should  be  thrown  about  them  to  see 
that  their  time  is  not  wasted.  Therefore,  it  is  one  of  the  most  sacred  duties  of  the 
authorities  of  the  training-school  to  take  every  precaution  to  insure  the  perfect  good 
health  of  candidates  for  admission.  It  is  not  sufficient  that  the  applicant  file  a 
certificate  of  health  from  a  neighboring  physician.  In  the  first  place,  such  physi- 
cian usually  has  never  examined  the  girl  carefully — that  is,  heart,  lungs,  kidneys, 
stomach,  and  genito-urinary  organs.  He  has  perhaps  seen  her  grow  up,  knows  that 
she  is  apparently  in  good  health,  and  gives  a  certificate  to  that  effect.  The  accept- 
ance of  every  candidate  for  admission  to  the  school  should  be  conditioned  upon  the 
passing  of  a  physical  examination,  made  by  some  one  connected  with  the  hospital 
and  school,  who  has  the  time  and  ability  to  do  this  work  faithfully.  The  training- 
school  may  be  in  need  of  pupils,  but  an  unhealthy  nurse  is  no  asset  to  a  school,  and 
it  is  no  kindness  to  take  a  girl  into  the  school  who  has  the  signs  of  incipient  disease. 

Most  of  these  girls  have  lived  pretty  even  lives:  they  have  not  been  worked 
under  pressure  at  their  homes,  as  a  rule,  and  consequently  their  vitality  has  not 
been  drawn  on  to  any  great  extent,  so  that  perhaps  they  may  be  apparently  very 
healthy  when  they  come  up  for  admission;  but  the  training  is  not  an  easy  life,  and 
there  are  times  when  it  is  extremely  hard.  The  girls  are  sometimes  worked  to 
their  utmost  capacity,  and,  unless  they  have  the  foundation  of  a  robust  constitution, 
and  unless  their  vital  functions  are  in  good  order,  they  are  almost  certain  to  develop 
some  disease  that  will  make  them  unsatisfactory  for  their  further  training  or  the 
after  life  of  a  trained  nurse.  Especially  is  it  necessary  to  look  into  the  girl's  physical 
condition  for  signs  of  tuberculosis  and  heart  disease.  A  good  many  of  these  girls 
have  been  brought  up  in  the  country  with  plenty  of  outdoor  exercise.  As  soon  as 
they  are  shut  within  the  walls  of  the  hospital  and  herded  with  sickness  of  all  kinds, 
it  is  not  difficult  to  imagine,  first,  breaking  health,  and,  second,  the  development 
of  some  disease  toward  which  they  may  have  a  tendency,  either  by  heredity  or 
by  reason  of  weak  organs  somewhere. 

These  girls  have  usually  lived  very  regular  lives  as  to  their  food,  rest,  and 
exercise.  One  of  the  first  signs  that  the  training-school  is  too  much  for  the  pupil  is 
a  loss  of  appetite.  Being  ambitious,  the  girl  makes  every  effort  to  hold  her  own  and 
do  her  work.  She  acquires  a  functional  disorder  of  the  stomach,  which  very  often 
is  a  prelude  to  functional  heart  lesions,  which  may  after  a  time  become  permanent 


312  OPERATION    OF    THE    HOSPITAL 

organic  affairs.  Stomach  disorders,  to  which  girls  in  the  training-school  are 
often  subject,  eventuate  very  frequently  in' gastric  ulcer.  Just  why  this  is  the 
case  may  be  left  to  the  medical  profession.  We  are  only  interested  just  now  in 
the  fact. 

These  girls  very  frequently  have  incipient  eye  diseases.  Very  often  their  teeth 
are  in  bad  order,  and  not  infrequently  their  menstrual  apparatus  is  in  the  worst 
possible  condition.  It  is  a  peculiar  fact  that  many  pupil  nurses  have  disturbances 
of  menstruation  from  almost  the  moment  they  enter  the  training-school.  The  heads 
of  the  schools  tell  us  that  some  of  these  girls  menstruate  continuously  for  months 
after  they  begin  their  training,  and  some  of  them  have  been  known  to  go  for  a  year 
or  even  longer  without  menstruating  at  all,  though  they  may  have  had  perfect 
function  up  to  the  time  of  their  entering.  Just  why  this  is  true  is  another  of  those 
mysterious  things  that  we  must  leave  for  the  medical  profession  to  answer.  It  is 
a  common  occurrence,  however,  that  these  girls  of  irregular  menstruation  eventually 
leave  the  school  either  because  of  progressively  failing  health  or  from  inroads  made 
by  some  definite  disease  upon  a  devitalized  system. 

So  that,  again,  we  come  back  to  the  main  proposition  that  it  is  only  justice  to 
the  school  and  the  girl  that  a  very  careful  and  critical  physical  examination  be 
made  of  every  applicant  for  admission,  and  it  is  just  a  little  short  of  criminal  to 
accept  a  girl,  and  disarrange  the  whole  course  of  her  life,  until  every  endeavor  has 
been  made  to  assure  her  permanence  in  the  career  she  has  selected. 

The  Training-school  in  the  Small  Hospital. — There  are  some  special  institu- 
tions which  cannot  possibly  attract  young  women  who  wish  to  learn  the  profes- 
sion of  nursing,  as,  for  instance,  a  special  hospital  for  the  treatment  of  skin  dis- 
eases and  cancer,  or  an  eye  and  ear  infirmary,  where  the  training  would  be  far  too 
narrow.  In  all  such  institutions  as  these  it  is  almost  absolutely  necessary  to  employ 
young  women  who  have  already  had  their  training,  and  to  pay  them  the  salaries 
demanded  by  trained  nurses.  Fortunately  these  institutions  do  not  require  very 
many  nurses,  so  that  the  expense  of  nursing  the  sick  suffering  from  these  special 
afflictions  is  comparatively  small.  They  do  not  require  many  nurses,  largely  for 
the  reason  that  nearly  all  the  nursing  in  them  is  of  so  technical  a  character  that  it 
is  done  by  newly  graduated  medical  men.  Just  here  it  might  be  suggested  that  if 
the  profession  of  trained  nursing  was  on  a  higher  plane  than  it  is  at  the  present 
time,  nurses  could  do  this  technical  work,  and  they  ought  to  do  it.  The  labora- 
tories of  pathology  all  over  the  world  employ  trained  women  as  skilled  technists 
to  do  special  staining  and  work  that  requires  skilful  and  well-trained  fingers,  and 
that  does  not  require  a  very  great  amount  of  originality.  There  is  no  good  reason 
why  these  special  hospitals  should  not  look  to  the  trained  nurse  for  this  work 
also.  It  is  a  fact,  however,  that  unless  she  has  a  medical  education,  which  pre- 
supposes a  fundamental  intellectual  training,  the  trained  nurse  is  not  doing  this 
technical  work  in  the  special  hospital. 

A  good  many  of  these  special  hospitals  are  attempting,  against  vast  odds,  to 
conduct  a  training-school,  and  their  failure  is  evidenced  by  the  fact  that  all  over 
the  country  they  are  attempting  to  make  arrangements  for  temporary  exchanges 
of  pupils  with  other  hospitals,  so  that  the  maternity  hospital,  for  instance,  may 
send  its  pupils  to  an  institution  engaged  in  work  in  some  other  direction,  and  the 
large  general  hospitals  of  the  country  are  solicited  continuously  to  participate 
in  this  exchange.  If  they  acquiesce,  however,  they  are  giving  something  for 
nothing.  It  would  be  of  little  service  to  a  general  hospital  to  send  its  pupil  nurses 
to  a  maternity  hospital  for  special  training  in  that  branch  of  the  profession,  be- 
cause they  have  a  maternity  department  of  their  own,  and  so  with  all  of  the  other 


THE    MODERN    TRAINED    NURSE  313 

branches.  So  that  the  special  hospital,  attempting  to  operate  a  training-school, 
is  having  a  continuously  harder  time  to  secure  pupils,  and,  without  question,  the 
time  is  near  at  hand  when  they  will  have  to  be  satisfied  with  a  mediocre  class  of 
pupils,  who  will  be  so  badly  and  one-sidedly  trained  at  the  expiration  of  their  pupil- 
age that  they  will  be  of  little  value  in  the  community  as  private  nurses.  As  a  rule, 
there  are  not  enough  of  these  special  hospitals  in  a  community  or  near  to  each 
other  to  make  a  profitable  exchange  possible.  Besides  that,  the  large  training- 
schools  of  the  country  are  turning  out  so  many  graduates  of  varied  training  that 
the  one  who  has  had  a  training  only  in  one  small  branch  of  her  profession  can 
hardly  hope  to  succeed  in  such  a  one-sided  competition.  All  these  special  hospitals 
must  sooner  or  later  dissolve  their  training-schools  and  work  with  nurses  graduated 
from  other  institutions. 

Now  let  us  take  the  small  general  hospital  of,  say,  50  beds.  The  training-school 
of  such  an  institution  will  depend  almost  entirely  on  the  personal  equation  and 
the  ability  of  the  heads  of  the  institution  to  devise  a  competent  training  for  its 
pupils.  There  is  no  good  reason  why  the  small  hospital  should  not  give  quite  as 
good  a  training  to  the  pupil  nurse  as  the  larger  one.  The  relationship  between  the 
pupil  and  teacher  will  be  a  closer  one,  the  individualism  will  be  greater,  and  the 
few  nurses  in  such  an  institution,  properly  conducted  by  clever  women,  will  bear 
the  same  relationship  to  the  pupils  of  the  large  hospitals  as  the  young  man  who 
is  able  to  afford  a  private  tutor  will  bear  to  the  great  majority  of  boys  who  must 
shift  for  themselves  without  very  much  personal  contact  with  their  teacher,  and 
with  almost  no  personal  advice,  counsel,  and  direction.  It  is  true  that  the  small 
hospital  will  not  have  so  many  maternity  cases  nor  so  many  surgical  operations, 
but  it  will  be  a  case  of  quality  versus  quantity.  Attendance  on  one  normal  labor, 
under  proper  individual  direction  by  a  good  teacher,  a  master  in  his  profession, 
will  teach  the  nurse  more  than  a  dozen  such  cases  where  the  obstetrician  and  the 
head  nurse  pay  little  attention  to  the  pupil  as  to  the  details  of  her  work.  The 
same  will  be  true  in  the  operating-room — in  the  great  hospital  there  may  be  twenty 
cases  of  surgery  a  day,  in  the  small  hospital  two.  In  the  one  case,  the  pupil  just 
entering  the  operating-room  is  a  very  insignificant  part  of  a  great  machine,  and 
her  duty  for  weeks  will  be  to  pick  up  sponges  and  hang  them  on  a  rack,  and  to 
clean  instruments  at  the  close  of  the  day's  work;  whereas,  in  the  small  institution 
she  is  a  large  cog  perhaps,  at  once,  one  of  two  or  three  nurses  who  must  do  not 
only  the  menial  labor  connected  with  surgical  procedure,  but  who  must  at  once 
go  into  the  technic  of  sterilization,  asepsis,  the  preparation  of  patients,  and  at- 
tendance upon  the  surgeon.  Again,  there  will  come  the  quality  versus  the  quantity 
of  the  work  done,  and  the  success  or  failure  of  the  nurse  in  the  small  institution 
will  depend  more  largely  upon  the  teaching  capacity  of  those  who  are  responsible 
for  her  education  than  the  difference  in  the  number  of  cases  treated  in  the  two 
institutions. 

Unfortunately,  it  not  always  happens  that  the  teachers  are  as  well  equipped 
for  their  duties  in  the  small  institution  as  in  the  large.  The  small  hospital  cannot 
afford  to  pay  the  salary  that  the  head  nurse  can  command  in  the  larger  one.  The 
duties  of  the  head  nurse  or  teacher  in  a  small  institution  an'  more  varied  and 
more  exacting,  and  perhaps  the  hours  will  be  longer  than  in  the  large  one.  and  it  too 
often  happens  that  the  head  nurse  in  the  small  institution  lias  other  duties  to  per- 
form than  those  directly  pertinent  to  her  particular  field  of  action.  She  may  have 
the  institution  to  look  after,  or  the  diet  to  supervise,  or  she  may  even  be  the  pur- 
chasing agent  for  the  hospital,  and  in  some  eases  may  be  relegated  for  a  pari  of 
her  time  to  the  office,  in  the  keeping  of  the  accounts  and  taking  care  of  the  ad- 


314  OPERATION    OF   THE    HOSPITAL 

mission  of  patients;  so  that,  however  capable  she  may  be,  she  will  not  have  the 
time  to  give  to  the  proper  training  of  the  pupils  in  the  school. 

Training-school  in  the  Large  General  Hospital. — Now  let  us  take  up  the  train- 
ing-school in  the  large  general  hospital.  The  duties  of  the  pupil  nurse  in  this 
institution  are  quite  the  same  as  those  of  the  small  general  hospital,  so  that  when 
we  discuss  the  one  we  are  quite  at  the  same  time  discussing  the  other.  If  we  have 
anything  to  offer  for  the  information  of  the  one  the  same  would  be  true  of  the 
other. 

At  the  very  outset  let  us  contemplate  the  relationship  of  the  training-school 
to  the  hospital.  They  are  not  the  same,  and  in  quite  a  number  of  institutions 
within  the  past  few  years  the  training-school  has  been  organized  under  a  separate 
charter  and  operated  under  a  different  board  of  directors,  and  kept  in  every  way 
completely  apart  from  the  hospital,  excepting  that  the  pupils  of  the  training-school 
are  employed  under  certain  definite  and  fixed  conditions  to  nurse  the  patients  in 
the  hospital.  Such  a  dual  organization  as  this  makes  the  ethics  of  the  whole 
situation  far  simpler  than  where  the  training-school  is  a  part  of  the  hospital  and 
operated  in  conjunction  with  it,  but  the  mere  fact  that  a  training-school  can  be 
operated  independently  of  a  hospital  is  evidence  that  the  training-school  is  not  the 
hospital.  What,  then,  is  the  attitude  of  the  training-school  toward  the  hospital, 
and  what  the  ethics  of  the  situation  from  the  view-point  of  the  hospital  and  its  com- 
ponent elements;  that  is,  the  medical  staff  and  the  superintendent  and  the  patients? 
The  nurse  in  the  institution,  as  a  cog  in  a  big  machine,  is  not  a  pupil  at  all,  but  a 
trained  nurse,  present  to  perform  the  specific  duties  of  a  trained  nurse,  and,  in  so 
far  as  her  hospital  duties  are  concerned  she  is  answerable  not  to  the  directors  of 
the  training-school,  but  to  those  who  are  responsible  for  the  care  of  patients  in  the 
institution,  and  her  direction  by  the  superintendent  of  the  training-school,  and  the 
head  nurses  of  the  various  departments  of  the  hospital,  are  merely  for  the  purpose 
of  the  supervision  of  her  work,  and  to  see  that  she  does  it  efficiently.  So  far  as  her 
duty  is  concerned  in  the  care  of  a  patient,  she  is  responsible  to  the  physician  in 
charge  of  that  patient,  and  to  the  superintendent  of  the  hospital,  whose  duty  it  is 
to  see  that  the  patient  has  all  the  facilities  that  the  hospital  can  afford  under  the 
doctor's  orders.  Then  the  nurse  is  responsible  to  the  superintendent  of  the  hospital, 
and  the  training-school  head  who  ignores  this  relationship,  that  is,  who  assumes 
that  the  doctor  and  the  superintendent  of  the  hospital  have  nothing  to  do  with 
the  conduct  of  the  nurse,  is  relegating  to  herself  a  position  of  responsibility  that 
does  not  belong  to  her.  In  some  institutions  there  is  a  training-school  rule  that 
a  physician  who  wants  to  give  an  order  concerning  a  patient  must  give  it  to  the 
head  nurse  or  the  head  of  the  training-school.  This  rule  makes  it  necessary  for  a 
doctor's  order  to  go  through  two  or  three  people,  in  which  case  the  responsibility 
for  the  execution  of  the  order  is  so  finely  divided  by  the  nurse,  and  the  head  nurse, 
and  the  superintendent  of  the  training-school,  that  it  will  be  extremely  difficult 
to  find  a  culprit  if  the  order  is  not  executed  or  is  improperly  carried  out.  So  that 
it  would  seem  highly  proper,  if  not  absolutely  necessary,  that  orders  from  the 
doctor  concerning  a  patient  should  be  given  directly  to  the  nurse  on  the  case,  and 
it  is  the  experience  of  most  hospital  administrators  that  unless  orders  are  written, 
and  made  a  part  of  the  record,  it  is  almost  impossible  to  convict  any  nurse  of  a 
failure  to  carry  them  out  as  intended. 

It  would  seem,  then,  that  for  purposes  of  hospital  administration  the  training- 
school  as  an  entity  is  practically  wiped  out,  and  that  the  individual  nurse  is  an- 
swerable to  the  individual  doctor,  and,  since  the  superintendent  of  the  whole 
institution  is  placed  there  by  the  board  of  directors  to  look  after  the  efficient  carry- 


THE    MODERN   TRAINED    NURSE  315 

ing  out  of  all  the  work  of  an  institution,  it  would  seem  that  the  individual  nurse  is 
likewise  responsible  to  the  superintendent  of  the  hospital  for  her  share  in  the  care 
of  the  patient.  Let  it  not  be  understood  that  this  dual  role  of  the  nurse — that  is, 
to  the  doctor  in  the  care  of  his  patient,  and  to  her  superiors  as  a  pupil  in  the  training- 
school — is  an  impossible  one.  In  most  institutions  the  relationship  works  out  well, 
and  the  superintendent  of  the  training-school  is,  in  effect,  the  head  nurse,  charged 
with  the  care  of  patients. 

Distribution  of  Nurses. — The  day  has  gone  by  when  attending  men,  whether 
it  be  in  the  private  pay  wards  or  private  rooms  or  the  free  public  wards  of  an 
institution,  will  be  satisfied  with  a  service  that  contemplates  one  nurse  to  fifteen 
or  twenty  patients.  In  the  old  days,  when  we  knew  almost  nothing  about  path- 
ology, urinalysis,  bacteriology,  and  when  we  did  not  apply  the  principles  of  hydro- 
therapy and  electrotherapy  and  scientific  diet  in  the  care  of  patients  to  the  extent 
that  we  use  these  things  to-day  on  the  wards  of  every  modern,  well-operated  in- 
stitution, the  duties  of  the  nurses  were  mainly  to  wait  on  the  patient  and  to  give 
the  medicine.  We  are  not  ushu^ery  much  medicine  to-day,  and  we  are  doing  a 
myriad  of  physical  things  for  the^fttefit  of  patients,  such  as  tubbing,  enemas,  wet 
dressings,  irrigations,  massage  and  movement  treatment,  and  the  like,  so  that  the 
nurse,  working  in  the  average  institution  in  attendance  on  acute  cases,  will  do  won- 
derfully well  if  she  can  carry  out  the  orders  of  the  modern  practitioner  of  either 
medicine  or  surgery  for  two  or  three  patients  for  twelve  hours  at  a  stretch,  and 
it  is  almost  axiomatic  that  the  institution  that  employs  fewer  than  one  nurse  to 
every  two  or  three  patients  is  not  keeping  well  up  in  the  march  of  progress  among 
modern  institutions  for  the  enlightened  care  of  patients  under  the  demands  of 
modern  medicine  and  surgery.  Enlightened  public  opinion  is  coming  well  round 
to  a  position  in  which  benefactors  of  institutions  before  giving  their  money  will 
want  to  know  just  what  care  the  poor,  that  they  are  giving  their  money  to  benefit, 
are  actually  receiving  at  the  hands  of  the  institution  asking  for  their  aid.  The 
best  thought  in  the  enlightened  community  of  the  day  is  drawing  a  very  light  line 
between  what  a  wealthy  private  patient  should  have  in  the  way  of  service  and  the 
service  to  be  accorded  the  pauper  in  the  public  ward.  "The  man  is  sick;  take  care 
of  him!"  These  are  the  words  of  injunction  that  will  accompany  the  average  pauper 
to  the  hospital  to-day  in  the  note  asking  that  he  be  taken  in.  It  will  not  do  to  say 
to  this  large  patron  of  the  institution  that  this  patient  requires  an  x-ray  picture, 
but  x-ray  pictures  cost  money.  It  will  not  do  to  say  that  this  child  suffering  from 
the  results  of  a  poliomyelitis  needs  constant  and  persistent  electric  movement  of 
the  affected  part,  but  that  these  cost  money,  and  require  the  undivided  attention 
for  hours  each  day  of  a  nurse  or  doctor;  it  will  not  do  to  say  that  this  burned  child 
needs  the  continuous  bath,  but  that  the  continuous  bath  calls  for  the  uninterrupted 
service  of  a  nurse,  and  nurses  cost  money,  therefore,  the  child  must  suffer. 

Yet  there  must  be  a  difference  between  the  service  given  to  a  millionaire  and  a 
pauper,  but  that  service  should  be  wholly  of  the  luxuries.  The  pauper  need  not  have 
broiled  quail  and  asparagus  tips  for  dinner,  and  he  need  not  have  a  private  room 
with  adjoining  bath,  with  roses  on  every  stand  and  the  odor  of  perfumes  scenting 
the  room;  but  these  extras  should  be  the  only  ones  that  the  man  of  millions  should 
have  that  the  pauper  should  not  have;  and  patrons  of  wealth  and  refinement  and  of 
humanitarian  instincts  will  give  thousands  annually  to  the  institution  where  they 
know  the  poor  are  getting  everything  that  a  rich  man  can  get  that  is  needful, 
where  they  will  give  begrudgingly  a  few  paltry  dollars  to  the  institution  that  they 
know  is  neglecting  the  wants  and  welfare  of  the  poor. 

The  number  of  nurses,  therefore,  is  largely  a  measure  of  the  service  given  to 


316  OPERATION    OF   THE    HOSPITAL 

its  sick  by  an  institution;  and  no  nurse,  however  capable,  can  conscientiously  give 
an  adequate  service  to  more  than  two  or  three  acutely  sick  people. 

The  Flying  Squadron. — In  the  best-managed  institutions,  from  the  standpoint 
of  their  nursing  corps,  there  is  a  sort  of  "flying  squadron" — that  is,  a  certain  num- 
ber of  pupil  nurses  who  can  be  moved  at  short  notice  from  one  point  to  another: 
if  the  work  in  maternity  is  heavy,  the  flying  squadron  is  sent  there,  to  be  instantly 
moved  to  some  other  point  when  no  longer  needed.  The  great  trouble  is  that 
head  nurses  are  too  often  not  taught  to  do  team  work,  and  are  not  sufficiently  encour- 
aged in  an  esprit  du  corps.  If  they  find  it  difficult  or  impossible  to  get  additional 
help  speedily  when  they  call  for  it,  they  are  very  likely  to  exaggerate  their  regular 
and  constant  needs,  so  that  they  can  keep  enough  nurses  to  be  guaranteed  against 
running  short-handed  when  the  rush  comes. 

Training-school  Heads. — There  must,  of  course,  be  a  superintendent  of  every 
training-school,  and  what  a  wonderful  woman  the  ideal  superintendent  of  the 
training-school  is!  She  should  be  not  only  a  good  teacher,  a  good  administrator, 
a  good  nurse,  and  a  good  woman;  she  must  be  filled  with  the  humanities;  she  must 
be  an  exponent  of  the  "square  deal."  She  must  be  a  good  friend  and  an  illuminating 
example.  No  woman  can  measure  up  to  all  these  things  this  side  the  pearly 
gates,  but  the  best  superintendent  of  a  training-school  will  be  the  woman  who  has 
most  of  these  virtues.  She  has  not  only  to  train  nurses;  her  most  important  duty 
is  to  guide  young  women  at  the  very  outset  of  their  careers  along  the  best  lines. 
Most  of  the  young  women  who  enter  the  training-school  are  only  half-made  women. 
They  are  but  half-bridled  in  their  moral  and  mental  as  well  as  their  physical  make- 
up. It  will  be  the  duty  of  the  superintendent  of  the  training-school  to  mature  these 
young  women  along  proper  channels,  to  teach  them  good  morals,  truthfulness, 
conscientiousness,  devotion  to  duty,  unselfishness,  to  teach  them  to  think  less  of 
themselves  and  their  pleasures  and  comforts,  and  more  of  the  happiness  and  com- 
fort of  others. 

If  the  superintendent  measures  up  to  the  virtues  that  ought  to  be  hers,  the 
training-school  will  take  care  of  itself.  Her  assistants  will  have  high  ideals.  They 
will  be  true  to  her  purposes  and  her  conception  of  things  as  they  should  be,  and, 
if  the  heads  of  the  training-school  look  high  for  their  ideals,  the  pupils  will  not 
have  their  eyes  toward  the  ground. 

It  may  be  doubted  whether  the  efficiency  of  a  training-school  is  increased  by 
the  too  long  dominance  of  one  head  of  a  department.  Training-school  women 
will  say  this  is  rank  heresy — that  the  longer  a  principal  of  a  department  remains 
there  the  more  valuable  her  services  will  be.  In  the  experience  of  some  of  us,  this 
is  not  true.  Up  to  a  certain  point,  the  efficient  nurse  will  progress  and  improve. 
Her  technic  will  become  more  and  more  perfect.  Her  service  to  the  doctor  will 
become  more  and  more  valuable;  but,  after  a  certain  period  of  time  in  one  position, 
the  trained  nurse  regards  her  work  as  of  a  perfunctory  character;  she  ceases  to 
progress;  she  nearly  always  slights  some  of  the  doctors  to  give  unnecessary  atten- 
tion to  others;  she  ceases  to  be  a  good  teacher  after  a  while,  and,  having  clone  the 
same  thing  in  the  same  way  so  long,  she  expects  the  new  pupil  to  spontaneously 
do  the  thing  her  way,  and  when  the  duty  is  performed  awkwardly  or  even  ne- 
glected the  director  who  has  rusted  out  loses  her  patience,  becomes  a  teacher  no 
longer,  but  a  censorious  critic,  and  too  often  a  common  scold.  Therefore,  nurses 
ought  to  change  their  occupation  in  an  institution.  This  theory  is  at  variance  with 
the  theories  held  by  nearly  all  training-school  women,  but  it  is  a  leaf  out  of  a  book 
of  experience  and  is  honestly  set  down  here. 

Discipline  in  the  School. — We  have  fixed  the  attitude  of  the  individual  pupil 


THE    MODERN   TRAINED    NURSE  317 

toward  the  hospital  as  a  nurse,  and  charged  her  with  duties  under  the  direction 
of  the  physician.  We  go  now  to  the  discipline  of  the  training-school,  by  which  the 
pupil  is  taught  her  attitude  as  a  nurse  in  the  world  of  nursing. 

A  good  many  erroneous  ideas  seem  to  prevail  at  the  present  time,  growing 
perhaps  out  of  a  misunderstanding  of  the  nursing  problem — the  training-school 
head,  on  the  one  hand,  may  assume  that  the  whole  hospital,  in  all  of  its  parts,  is 
subservant  to  the  training-school  as  a  disciplinary  and  educational  institution  for 
the  training  of  young  women  to  become  nurses.  The  mental  attitude  of  this  sort 
of  training-school  head  toward  the  patient  in  the  hospital  is  rather  a  nonchalant 
one;  the  patient  is  merely  a  part  of  the  nurse's  training — so  much  material  upon 
whom  she  may  practice;  if  a  mistake  is  made,  costly  or  otherwise,  it  is  unfortunate, 
but  perhaps  a  good  lesson  for  the  pupil. 

The  other  attitude,  sometimes  assumed  by  the  hospital  administrator,  is  one 
that  regards  the  patient  as  the  whole  consideration  at  issue,  and  is  the  sum  total 
of  the  day's  work  of  the  pupil  nurse.  Both  these  attitudes  would  seem  to  fall  some- 
what short  of  a  just  summing  up  of  the  status.  Without  any  question  the  patient 
is  the  primary  consideration,  and  the  carrying  out  of  the  doctor's  orders  to  the  end 
that  his  patient  may  get  well;  but  at  the  same  time  the  care  of  the  patient  should 
he  an  experience  for  the  nurse  and  a  part  of  her  education.  The  ideal  head  of  the 
training-school,  therefore,  would  seem  to  be  a  woman  whose  chief  ambition  is  to 
take  care  of  the  patient,  and,  at  the  same  time,  teach  the  nurse;  the  first,  by  teach- 
ing her  pupil  to  obey  the  doctor's .  orders,  and  the  second,  by  furnishing  proper 
instruction  concerning  the  reasons  why  such  orders  were  given. 

The  discipline  of  most  training-schools  seems  to  be  toward  militarism.  Pupils 
are  taught  to  arise  when  a  superior  enters  their  presence.  They  are  taught  prece- 
dence in  entering  or  leaving  a  room,  and  the  casual  observer  on  the  floors  of  the 
general  hospital  will  remark  the  precision,  it  might  be  said  the  spectacular  carrying 
out  of  these  disciplinary  rules.  Without  any  question  such  rules  are  valuable. 
They  are  valuable  in  teaching  obedience  of  orders,  valuable  in  pointing  out  the 
deference  clue  to  superiors,  in  maintaining  self-control  in  the  pupils,  and  in  assur- 
ing a  certain  amount  of  humility  of  spirit  in  young  women,  who  would  perhaps  other- 
wise grow  sometimes  rebellious  and  impatient  of  authority.  But  let  us  contemplate 
for  a  moment  a  branch  of  training-school  discipline  that  seems  not  to  be  quite  so 
important  in  most  institutions;  we  might  call  this  training-school  politics.  Every 
medical  man,  whose  work  keeps  him  on  the  wards  of  a  hospital  in  which  there  is  a 
training  school,  understands,  to  his  cost,  what  training-school  politics  stand  for. 
It  stands  for  favoritism  and  injustice.  If  there  is  a  military  discipline  in  some  train- 
ing-schools concerning  the  outward  show,  there  is  in  other  training-schools  a  perfect 
organization  of  espionage,  in  which  the  spy  system  is  elevated  to  the  plane  of  a  fine 
art.  In  this  class  of  training-schools  the  whole  domestic  life  of  the  pupil  is  warped 
and  stunted,  and  made  miserable  by  the  necessity  either  to  placate  the  spies,  who 
are  always  known,  or  to  conduct  themselves  so  warily  as  to  hoodwink  the  spies. 
These  regimes  of  espionage  may  be  again  divided  into  two  classes — first,  those  in 
which  the  spies  are  set  merely  to  keep  the  director  of  the  school  informed  for  the 
legitimate  purpose  of  school  discipline;  in  the  other  class,  the  spies  are  maintained 
for  the  purpose  of  feeding  the  vanity  and  personal  ambition  of  the  head  of  the 
school.  It  is  needless  to  say  this  last  phase  of  the  spy  system  is  the  bane  of  train- 
ing-school existence.  The  pupil  has  no  moment  in  which  she  may  speak  her  mind 
about  her  superior  in  that  peculiarly  harmless,  inoffensive  way  thai  girls  have. 
She  must  always  guard  her  tongue  even  in  the  abandon  of  her  own  room.  If  she 
speaks  of  her  superiors  it  must  be  done  in  an  adulatory  vein.     She  know-  that  her 


318  OPERATION   OF   THE    HOSPITAL 

little  girlish  indiscretions  will  be  carried  to  her  superiors,  grossly  exaggerated  into 
perhaps  heinous  offenses,  and  she  knows  that  the  directors  of  the  school,  that  will 
permit  a  system  of  spying  and  tale-bearing  such  as  this,  are  quite  small  enough 
and  vindictive  enough  to  mete  out  surreptitiously,  and  by  indirection,  a  punish- 
ment out  of  all  proportion  to  the  offense  committed.  So  that,  in  such  a  school  as 
this  there  must  always  be  built  up  a  counterplot.  The  pupils  become  habitual 
sneaks  and  liars  and  sycophants.  These  girls  are  getting  their  training  in  this 
school,  not  only  as  nurses,  but  as  women,  and  if  they  are  forced  into  petty  vices, 
are  driven  to  insincerity,  it  is  an  easy  stage  to  the  next  step  which  carries  these  same 
petty  vices  into  the  care  of  the  sick.  The  girl,  a  part  of  whose  training  this  is,  will 
find  it  easy  presently  to  record  a  temperature  not  taken,  to  mark  down  a  medicine 
not  given,  to  omit  some  order  of  vital  importance,  and  to  record  it  as  having  been 
carried  out. 

In  every  walk  of  life  the  keynote  of  the  education  of  the  young  is  the  lesson  in 
truthfulness,  honesty,  sincerity,  and  so  it  would  seem  for  the  pupil  in  the  training- 
school;  if  she  is  taught  these  virtues,  and  if  they  are  inculcated  as  a  part  of  her 
daily  life,  they  will  eventually  be  a  part  of  her  very  nature. 

The  Teaching  of  Probationers. — We  have  now  considered  somewhat  the  train- 
ing of  the  pupil  nurse  in  morals  and  mariners,  in  her  social  and  domestic  life,  and  in 
the  molding  of  her  character.  Let  us  now  briefly  discuss  her  training  in  those 
things  that  appertain  especially  to  her  vocation — that  is,  the  care  of  patients. 

Without  any  question,  the  days  of  primest  importance  to  the  pupil  in  the 
training-school  are  those  of  her  probation.  She  is  clay  in  the  hands  of  the  potter ; 
she  doesn't  know  what  is  expected  of  her,  and  has  no  sense  of  the  proportions  of 
responsibility;  she  cannot  know  where  her  duties  begin  and  those  of  other  people 
end,  so  that  it  is  the  very  alphabet  of  her  profession  that  she  must  learn  immediately 
upon  entering  the  school,  and,  in  order  that  she  may  learn  her  first  lessons  well,  she 
must  have  a  good  teacher;  it  is  essential  that  every  woman  in  authority  over  pupil 
nurses  shall  be  efficient  and  patient,  and,  at  the  same  time,  have  the  knack  of  impart- 
ing what  she  knows  to  others.  But  the  teacher  of  probationary  nurses  must  be 
the  one  woman  in  a  thousand.  It  is  common  knowledge  in  training-schools  that 
the  pupil  does  not  develop  her  true  character  until  after  she  has  been  accepted  into 
the  school.  The  reason  for  this  is  evident:  she  is  on  her  very  best  behavior.  If 
there  is  a  question  between  two  lines  of  conduct,  the  one  active  and  the  other 
passive,  she  chooses  the  passive,  because  it  is  almost  certain  that  that  course  will 
at  least  keep  her  out  of  trouble.  She  is  anxious  to  please.  She  does  not  know  how 
to  do  so  actively,  so  she  assumes  a  humility  and  timidity  that  is  artificial,  and  unless 
she  has  a  teacher  of  keen  discernment,  who  can  read  beneath  the  surface  and  who 
will  study  the  individual  in  order  to  direct  her  properly,  the  girl  will  get  a  bad  start 
in  the  school. 

In  the  later  training  of  the  pupil  nurse  she  will  have  a  number  of  teachers, 
those  who  wall  direct  her  work  at  the  bedside,  and  those  who  will  teach  her  the  theo- 
ries of  her  profession.  At  the  outset  there  should  be  one  teacher,  who  should  be  a 
mentor  or  tutor,  and  who  should  direct  her  every  step.  The  ideal  way  to  teach 
these  young  women  at  the  very  start  is  to  take  them  into  the  wards  and  let  them 
watch  the  older  pupils  do  their  work.  The  teacher  must  be  present,  explain  why 
things  are  done  so,  and  in  doing  her  first  work  the  pupil  must  not  be  clothed  with 
any  responsibility ;  that  is,  if  she  is  asked  to  place  a  bed-pan,  it  must  be  understood 
that  it  is  solely  for  her  practice,  and  has  nothing  to  do  with  the  patient's  comfort  or 
wants;  she  becomes  less  nervous  under  such  conditions.  This  is  the  plan  of  teach- 
ing little  children — the  object  lesson  method — and  it  will  be  astonishing  how  much 


THE   MODERN   TRAINED    NURSE  319 

even  the  dullest  pupil  will  learn  in  a  few  hours  under  the  proper  direction  of  a  careful 
teacher,  and  she  will  learn  to  do  things  right  at  the  very  outset,  and  she  will  never 
do  them  wrong  afterward.  In  this  way  she  can  be  carried  through  the  wards  and 
into  every  detail  of  ward  work;  she  can  be  taught  in  a  few  hours,  or  at  least  a  few 
days,  the  use  of  every  piece  of  apparatus — hot-water  bags,  enema  outfits,  the  making 
and  changing  of  the  bed  while  the  patient  is  lying  on  it.  In  a  few  days,  with  this 
kind  of  direction,  the  young  nurse  can  be  made  to  take  her  part  in  the  ward  work. 

If  on  the  contrary  the  green  country  girl  who  has  never  been  on  the  wards 
of  a  hospital  is  turned  over  to  the  businesslike,  efficient,  and  busy  head  nurse,  and 
is  immediately  held  accountable  for  wrongdoing,  she  will  get  nervous,  learn 
things  wrong,  and  it  will  be  a  long  time  before  she  ever  gets  them  right.  There 
are  very  few  head  nurses  who  are  worth  very  much  as  trainers  of  beginners;  as  a 
rule,  they  have  little  patience  with  ignorance  and  inefficiency,  their  whole  minds 
are  on  the  comfort  and  intelligent  care  of  patients,  and  they  have  neither  time  nor 
inclination  to  stop  for  explanations,  or  to  show  the  simple  details  of  a  procedure  to 
a  slow-minded  beginner. 

Nearly  all  of  us  have  seen  the  probationer  go  on  the  ward  of  a  hospital  to  report 
to  the  head  nurse,  and  have  seen  the  girl  so  nervous  at  having  been  clothed  with 
responsibility  at  the  bedside  of  a  sick  person  that  she  is  utterly  incapable  of  in- 
telligent action. 

Naturally,  the  very  best  person  to  assume  this  intimate  initiative  direction  of 
the  life  of  the  nurse  is  the  directress  of  the  nurses'  home;  naturally,  a  graduated 
head  nurse  who  knows  her  business.  In  any  event,  it  must  be  some  one  whom  the 
pupil  comes  in  contact  with  at  other  times  than  when  she  is  actually  on  the  wards 
at  work.  Perhaps  some  of  us  have  in  our  minds  such  a  woman,  who  will  slip  into 
the  room  of  the  new  probationer  at  bedtime,  with  a  word  of  comfort  to  the  girl 
who  is  for  the  first  time  away  from  home,  who  faces  the  world  all  by  herself,  and 
if  this  patient  teacher  will  let  the  girl  cry  a  little  bit  with  her,  it  will  not  only  do  the 
girl  a  lot  of  good,  but  its  effect  will  be  seen  in  the  next  day's  work  in  her  confidence 
in  her  teacher,  a  sort  of  motherly  confidence  as  it  were.  She  will  have  lost  her 
nervousness,  because  she  knows  her  teacher  is  her  friend,  and  that  her  mistakes 
will  not  be  charged  against  her,  and  so  she  will  make  fewer  mistakes. 

The  specific  duties  of  the  nurse  throughout  her  later  life  in  the  training-school 
will  naturally  come  more  properly  under  the  technical  operations  of  the  hospital. 
So  much  of  the  nurses'  duties  are  technical,  and  so  much  of  her  work  must  be  done 
precisely  and  within  rigid  lines,  that  it  would  seem  justified  if  we  take  up  these 
duties  in  a  special  section  on  the  Technic  of  the  Hospital,  and  which,  at  the  same 
time,  will  cover  the  duties  of  the  intern  and  those  minor  things  of  hourly  per- 
formance in  the  institution. 

Theoretical  Training  of  Nurses. — We  are  interested,  not  only  in  what  the  pupil 
nurse  shall  be  taught,  but  quite  as  much  in  who  shall  teach  her  in  the  duties  of  her 
profession.  Many  institutions  employ  special  graduate  nurses  to  lecture  to  the 
pupils,  who  hold  classes  and  quizzes  and  examinations  in  the  various  subjects. 
In  other  institutions  members  of  the  medical  staff  carry  on  this  work.  In  still 
other  institutions  members  of  the  house  staff  lecture  to  the  nurses  ami  conduct 
their  examinations  and  quizzes.  Many  superintendents  of  training-schools  are  at 
sea  over  this  problem.  They  find  it  difficult,  if  not  impossible,  to  persuade  the 
busy  members  of  the  medical  staff  to  lecture  to  the  nurses.  In  some  institutions 
a  few  of  the  more  prominent  members  of  the  staff,  who  have  a  good  deal  to  say 
about  the  hospital,  in  addition  to  the  performance  of  their  own  duties  as  Mall 
members,  insist  upon  the  most  exclusive  right  to  teach  the  nurses. 


320  OPERATION    OF    THE    HOSPITAL 

There  are  advantages  and  disadvantages  in  all  these  various  methods.  As 
a  rule,  members  of  the  attending  staff  have  been  out  of  school  so  long  that  it  is  no 
longer  possible  for  them  to  go  back  to  the  alphabet  of  the  various  branches.  It 
is  a  rare  case  where  a  surgeon,  even  if  he  has  the  time,  has  the  ability  to  appreciate 
the  mental  limitations  of  the  pupil  nurse — in  anatomy,  for  instance,  and  the  same 
will  be  true  of  all  of  the  other  branches.  The  teacher  who  is  a  master  of  his  pro- 
fession, well  along  in  years,  will  almost  invariably  assume  that  his  pupils  know  so 
much  of  the  subject  that  he  begins  over  their  heads,  and  never  gets  back  to  a 
point  where  they  understand  what  he  is  talking  about.  It  has  been  said  about 
educators  that  more  time  is  required  to  think  about  the  teaching  of  a  lesson  to  a 
small  child,  so  that  the  child  will  understand  it,  than  to  prepare  a  lesson  for  a 
member  of  the  graduate  class.  This  will  certainly  be  true  in  the  training-school, 
and  whoever  teaches  the  nurses  at  the  beginning  of  their  course  must  invariably 
set  out  with  a  quiz  and  a  general  discussion  of  the  subject  that  he  is  about  to  begin, 
in  order  that  he  may  ascertain  just  about  how  much  they  know  of  it. 

In  most  training-schools  the  idea  of  having  the  busy  members  of  the  staff  teach 
the  nurses  has  been  wholly  given  up,  for  the  reasons  that  they  are  too  busy  to  keep 
appointments  with  the  classes,  too  busy  to  prepare  the  lesson  they  are  to  teach,  and 
too  long  out  of  school  to  appreciate  the  ignorance  of  the  pupil. 

The  conduct  of  classes  by  graduate  nurses  has  even  greater  disadvantages. 
In  the  first  place,  it  is  extremely  difficult  to  teach  anything  to  anybody  merely 
by  thumb-rule  or  by  memory.  There  must  be  a  reason — why  is  this  done  so? 
The  graduate  nurse,  as  a  rule,  does  not  know  why.  She  herself  has  been  a  creature 
of  discipline.  As  a  rule,  she  knows  mathematically  and  in  detail  the  practice  of 
any  doctor  whom  she  is  serving  in  any  given  set  of  cases  and  under  nearly  all  cir- 
cumstances. She  knows,  for  instance,  what  a  certain  doctor's  treatment  of  post- 
partum cases  is,  what  aperient  is  given,  and  what  sort  of  binders  are  used  for  mother 
and  child,  and  how  they  are  adjusted;  but  rarely  does  she  know  the  reason  for  these 
things.  She  can  only  state  facts,  and  not  inculcate  lessons  by  appeals  to  reason,  so 
that  she  is  not  the  best  possible  teacher  for  the  pupil  who  is  expected  to  remember 
what  she  is  taught. 

Of  course  this  criticism  cannot  extend  to  the  few  specially  trained  women  of 
to-day  who  have  so  far  progressed  as  to  be  postgraduates  of  one  or  another  of  the 
few  universities  that  have  departments  for  fitting  young  women  to  teach  in  training- 
schools.  Columbia  University  is  perhaps  the  best  example  of  such  a  school,  and 
some  very  highly  trained  women  are  leaving  there  who  will,  perhaps  after  all,  solve 
the  question  of  who  shall  teach  the  nurses  in  the  training-school  in  the  theoretical, 
as  well  as  the  practical,  side  of  their  duties.  Only  one  word  more  just  here:  Is  it 
not  possible  for  these  specially  trained  women  to  gradually  overrate  the  capa- 
bility of  their  pupils,  and  attempt  to  give  them  something  that  they  are  not  quali- 
fied to  take — not  only  that,  but  there  seems  to  be  a  great  danger  that  these  specially 
trained  women  will  be  tempted  to  exaggerate  the  theoretical  side  of  the  training 
at  the  expense  of  the  practical  side. 

The  house  physicians  are  the  poorest  of  all  teachers  for  the  nurses.  In  the  first 
place,  these  young  men  have  themselves  come  into  their  junior  internship  with 
barely  more  practical  knowledge  than  the  nurses  themselves  possess.  Oftentimes 
there  are  nurses  who  can  teach  them  certain  details  of  the  hospital  work,  and  again 
they  have  no  personal  experience  upon  which  to  call  for  the  reasons  for  doing  things 
in  a  certain  way.  They  must  state  facts  merely,  oftentimes  quoting  from  the 
text-books.  These  young  men  too  have  just  come  from  the  medical  schools. 
Their  experience  of  life  has  not  been  great.     They  assume  that  because  these 


THE    MODERN    TRAINED    NURSE  321 

young  women  are  bright,  quick  witted,  and  quite  their  own  matches  in  conversation, 
that  they  are  also  their  equals  in  book  learning,  which  is  not  true.  Because  they 
learned  in  their  earlier  years  of  school  life  the  physiologic  action  of  drugs  upon 
certain  of  the  tissues  of  the  body,  they  assume  at  the  outset  of  a  lesson  on  materia 
medica  that  the  nurse  also  must  have  learned  these  things,  hence,  they  start  out 
upon  premises  that  are  artificial  to  the  nurse,  and  they  entangle  her  in  a  maze  of 
technicalities  and  scientific  phrases  and  text-book  learning  that  she  does  not 
appreciate,  therefore  she  will  not  learn.  There  is  another  phase  of  this  question  of 
the  teaching  of  nurses  by  the  house  staff — members  of  the  house  staff  are  young  men; 
pupils  in  the  training-school  are  young  women.  In  most  institutions  there  is  more 
or  less  of  an  effort  to  keep  these  young  people  apart,  in  the  interest  of  discipline 
and  good  government  and  efficient  work.  In  some  instances  the  effort  goes  so 
far  that  the  young  people  of  both  sexes  are  dismissed  if  they  are  discovered  to- 
gether, excepting  in  the  actual  performance  of  duty.  So  that  it  would  seem  almost 
tempting  fate  to  permit  these  young  men  to  lecture  to  the  nurses,  to  quiz  them, 
to  conduct  examinations,  written  and  oral,  and  to  exercise  that  certain  amount  of 
teacher-and-pupil  intimacy  necessary  in  class  work,  and  then  expect  them  to  hew 
to  the  line  so  closely  that  their  association  shall  end  at  that  point. 

Since  we  have  ruled  out  all  these  factors  in  the  teaching  of  a  pupil  in  the  train- 
ing-school, we  would  seem  to  be  left  almost  without  a  teacher  at  all.  But  there 
is  another  class,  namely,  the  younger  members  of  the  visiting  staff  of  the  hospital. 
These  young  men  have  nearly  always  served  their  internships  in  the  institution. 
They  have  now  gone  into  the  practice  of  their  profession;  they  know  the  technic 
of  the  institution  in  all  its  departments;  they  know  the  methods  and  procedure 
of  the  older  medical  members  of  the  staff.  They  have  had  a  vast  amount  of  experi- 
ence in  the  practice  of  medicine  as  the  pupil  nurse  will  see  it.  These  young  men 
have  been  in  such  close  touch  with  the  nurses  during  the  past  few  years  that  they 
know  the  limitations  of  these  young  women,  and  they  will  not  expect  unreasonable 
knowledge  on  their  part.  They  know  pretty  well  the  hard  places  in  the  road  the 
young  women  will  have  to  travel,  and  they  will  be  able  to  help  them  over  gracefully 
and  intelligently.  They  are  not  on  so  intimate  footing  with  the  nurses  as  the 
members  of  the  house  staff,  and  they  are  not  so  superior  to  the  nurses  as  the  older 
members  of  the  visiting  staff,  and  hence  there  is  a  certain  amount  of  comraderie 
between  these  two  elements  without  familiarity.  So  that  it  is  to  these  adjunct 
.young  workers  in  the  medical  staff  of  the  hospital  that  w^e  wall  be  able  to  look 
for  the  theoretic  training  of  the  nurses  in  the  institution. 

Experience  has  taught  that  it  is  not  well  for  one  teacher  to  teach  more  than 
one  subject  to  a  single  class.  One  who  is  teaching  one  subject  to-day  and  another 
to-morrow  will  find  it  almost  impossible  not  to  allow  one  to  intrench  upon  the  o1  her 
to  an  extent  that  will  hopelessly  entangle  the  minds  of  the  pupils.  Even  one  who 
teaches  physiology  and  materia  medica  will  find  that  his  toxicology  and  his  physio- 
logic action  of  drugs  will  so  enmesh  his  class  in  obscurities  and  ambiguity  that  the 
members  will  not  get  a  very  clear  idea  of  the  intention  of  the  teacher. 

It  would  seem,  then,  that  the  ideal  way  to  have  the  pupils  taught  the  theory 
of  nursing  is  by  the  younger  members  of  the  visiting  stall'  of  the  institution,  one 
teacher  for  each  subject. 

Necessity  for  Rigid  Technic. — We  have  agreed  elsewhere  that  the  pupil  nurse 
is  largely  a  creature  of  habit  and  discipline.  If  this  is  true,  and  it  might  be  added 
that  it  is  true,  not  only  in  the  training-school  for  nurses,  but  with  young  people 
in  every  walk  of  life,  then  we  must  arrange  the  work  for  these  young  people  within 
such  narrow  confines  that  they  will  learn  thoroughly  the  things  it  is  intended  they 


322  OPERATION    OP   THE    HOSPITAL 

should  know.  We  find  in  the  wards  of  the  hospital  that  the  older  medical  men 
are  a  good  deal  less  prone  to  observe  technicalities  and  the  necessities  of  technic 
than  the  younger  men,  for  the  reason,  perhaps,  that  the  older  men  are  falling  back 
largely  upon  their  experience,  not  only  professional,  but  in  the  affairs  of  life  gener- 
ally, and  as  the  volume  of  their  experience  grows  and  as  their  view-point  broadens 
the  fine  points  become  less  distinct,  and  the  details  blur  a  little;  the  next  stage 
after  this,  in  the  work  of  the  veteran  member  of  the  medical  staff,  is  carelessness,  a 
tendency  to  ignore  technic  in  all  its  branches,  and  it  is  at  this  stage  that  the  work 
of  the  veteran  physician  ceases  to  be  clearly  defined,  snappy,  and  up  to  date;  it 
is  the  beginning  of  the  end.  With  the  younger  men  discipline  is  everything, 
technic  is  paramount,  details  are  absolute  necessities,  and  their  work  will,  therefore, 
show  in  their  results.  So  it  is  with  the  pupils  in  the  training-school.  Where  the 
discipline  is  lax,  and  where  the  technic  is  diffuse  and  not  finely  demarked,  there 
will  presently  be  no  technic  at  all.  Once  convince  these  young  women  that  it 
makes  very  little  difference  whether  they  do  a  piece  of  technical  work  one  way  or 
another,  and  they  will  soon  cease  to  do  it  at  all,  and  will  regard  it  as  quite  an  in- 
significant matter.  We  have  called  attention  to  this  state  of  things  as  one  of  the 
disadvantages  in  maintaining  the  open-door  policy  in  the  hospital,  and  of  allowing 
the  medical  profession  at  large  the  freedom  and  courtesies  of  the  institution. 
When  the  nurse  is  attending  to  the  patient  of  one  man,  and  is  taught  to  do  certain 
things  in  a  certain  way,  and  is  then  compelled  to  reverse  her  technic  when  she 
goes  upon  another  case  for  some  other  physician,  she  will  become  slovenly  and 
indifferent,  and  is  very  apt  to  make  up  her  own  mind  that  technic  is  not  a  matter 
of  very  great  importance. 

So  that  in  every  well-regulated  and  systematically  operated  institution  there  is 
a  rigid  technic,  and  a  narrow,  emphatic  discipline  in  the  training-school.  Every- 
thing is  done  just  so,  and  no  changes  may  be  permitted  under  any  circumstances. 
Sometimes  this  discipline  reaches  an  embarrassing  point;  it  is  one  of  the  prime 
necessities  of  hospital  nursing  that  the  nurse  shall  obey  the  doctor's  orders.  If 
the  doctor  gives  an  order  that  is  wholly  contrary  to  the  teaching  of  the  pupil,  she 
is  sometimes  taught  to  refuse  obedience,  and  the  head  nurses  or  superintendent 
of  the  training-school  must  be  appealed  to  before  the  doctor  can  have  his  orders 
obeyed.  This  condition  of  things  is  not  always  an  unmitigated  evil,  because 
oftentimes  the  stranger  in  the  institution  who  has  an  occasional  patient  does  not 
do  things  according  to  modern  methods,  and  it  is  frequently  just  as  well  that  a 
point  be  made  of  some  one  order  that  he  may  want  to  give,  in  order  that  he  may 
understand  at  once  that  he  is  expected  to  do  technically  correct  practice,  and  he  will 
be  more  careful  if  he  is  called  to  time  by  even  a  pupil  nurse  or  a  probationer,  who 
may  have  to  tell  him  she  doesn't  know  how  to  do  it  his  way  and  that  she  has  been 
taught  differently.  It  must  not  be  understood  that  the  doctor's  orders  are  not  to 
be  carried  out  eventually,  but  that  no  pupil  nurse  is  allowed  to  carry  out  an  order 
of  her  own  volition  that  is  contrary  to  what  she  has  been  taught  without  consent 
of  her  superiors  in  the  training-school.  It  requires  a  good  deal  of  self-assertive- 
ness  on  the  part  of  the  pupil  nurse  to  disobey  the  order  of  a  commanding  figure  of  a 
medical  man,  and  she  will  have  to  be  supported  when  she  does  so.  When  such  an 
appeal  is  made  by  the  pupil  nurse  to  her  superiors  concerning  an  order  to  perform 
some  service  that  she  has  been  taught  is  improper  and  untechnical,  the  heads  of  the 
training-school  should  always  take  up  the  matter  with  the  doctor,  not  for  the  pur- 
pose of  arguing  him  out  of  his  own  opinion  as  to  what  should  be  done  with  his  case, 
but  merely  to  compel  him  to  place  his  order  in  specific  form,  and,  after  due  con- 
sideration, and  if  the  head  of  the  training-school  regards  the  order  as  improper 


THE    MODERN   TRAINED    NURSE  323 

and  one  that  should  not  be  carried  out,  then  she  in  turn  should  take  up  the  question 
of  the  conduct  of  the  physician  with  those  in  still  higher  authority,  whether  it 
be  the  chief  of  the  medical  staff  in  that  particular  department  or  the  superintendent 
of  the  institution  who  has  to  do  with  the  medical  men. 

The  point  that  should  be  emphasized  definitely  is  that  there  should  be  a  dis- 
tinct and  rigid  technic  in  all  parts  of  the  institution,  and  that  this  technic  should 
not  be  lightly  set  aside,  and  that,  when  it  is  set  aside  on  the  peremptory  order  of 
some  physician  in  attendance  on  a  patient,  it  is  at  the  end  of  a  good  deal  of  contro- 
versy and  argument,  in  order  that  the  whole  question  shall  have  due  weight  as  a 
departure  from  the  routine  practice  of  the  institution. 

Length  of  the  Course. — We  are  now  about  to  enter  upon  a  discussion  of  the 
time-worn  controversy  as  to  the  relative  merits  between  the  two-  and  three-year 
courses  of  training  for  pupil  nurses.  This  quarrel  is  a  classic  one,  and,  without  any 
question,  attempts  to  settle  it  have  been  commenced  at  the  wrong  point,  and  it 
will  be  settled  just  as  soon  as  training-school  authorities  and  hospital  administra- 
tors agree  on  what  is  expected  of  a  nurse,  and  not  before  that  time.  If  it  is  proposed 
to  make  a  half-educated  medical  attendant  out  of  the  pupil  nurse,  and  to  teach  her 
something  of  every  branch  of  medical  science,  then  the  quarrel  will  be  shifted  pres- 
ently with  a  two-year  proposition  left  as  a  dead  issue,  and  a  four-  or  five-year 
course  looming  in  the  distance.  If,  on  the  other  hand,  we  are  to  finally  agree  that 
the  duty  of  a  trained  nurse  shall  be  to  carry  out  in  an  intelligent,  dextrous,  and 
skilful  manner  the  orders  of  the  doctor  who  is  responsible  for  the  patient's  welfare, 
and  that  her  duty  wall  cease  there,  without  any  pretense  of  medical  technic,  then 
perhaps  the  two-year  advocates  will  have  a  "standing  in  court,"  so  to  speak,  and 
not  until  then. 

Is  there  not  a  happy  medium  between  the  long  course,  that  has  for  its  purpose 
deep  invasion  of  the  realms  of  medical  science  by  the  pupil  nurse,  and  that  far  shorter 
course  that  merely  fits  her  for  duties  a  little  above  that  of  the  menial?  And  can  we 
not  all  agree  that  in  three  years  a  young  woman  of  fair  education  and  good  sense 
should  be  able  to  master  the  essentials  of  a  scientific  care  of  the  sick,  learn  the  lessons 
of  responsibility  in  her  calling,  and  a  self-discipline  that  will  fit  her  for  the  serious 
work  of  her  profession  while  she  devotes  herself  to  a  full  day's  work  and  a  full 
night's  rest,  with  such  added  hours  and  days  of  recreation  as  all  the  schools  afford? 

This  question  could  be  met  and  settled  quicker  and  far  more  satisfactorily 
to  all  concerned,  but  for  the  existence  of  a  large  number  of  small  training-schools 
in  the  country  attached  to  private  hospitals  operated  for  profit,  and  for  no  other 
purpose.  The  administrators  of  these  hospitals  care  very  little  about  the  training 
of  a  nurse,  so  far  as  her  future  efficiency  and  her  own  interests  are  concerned;  their 
great  anxiety  is  to  obtain  the  services  of  as  many  pupils  as  they  can  get  without 
remuneration;  and  if  they  were  able  to  attract  a  sufficient  number  ci'  pupils  for  a 
three-year  course,  we  would  hear  no  more  about  the  two-year  course.  The  difficulty 
is  that  if  the  pupils  are  compelled  to  serve  three  years,  no  matter  where  they  ma- 
triculate, they  will  inevitably  go  to  the  larger  hospitals,  where  the  training  is  broader 
and  usually  better,  and  so  the  small  private  hospitals  will  be  compelled  to  employ 
graduate  nurses  to  do  their  work  and  to  pay  for  the  service. 

Hours  of  Duty. — We  have  now  another  classic  quarrel  on  our  hands — that  is,  the 
two-shift  versus  the  three-shift  service  in  the  hospital. 

Let  us  first  see  what  a  two-shift  nurse  has  to  do:  she  comes  to  her  breakfast  at 
7  o'clock.  She  is  on  duty  at  7.30,  and  works  until  12.30,  when  she  goes  to  dinner. 
She  is  back  on  duty  again  at  1.15,  and  works  until  3  o'clock;  then  she  has  two  hours 
off,  then  a  half-hour  of  work;  from  5.30  to  13.15  she  has  supper,  and  from  6.15  until 


324  OPERATION   OF   THE    HOSPITAL 

7.30  she  works.  At  8  o'clock,  three  times  a  week,  she  has  classes.  Adding  up  all 
of  this  time,  the  day  nurse  in  the  two-shift  service  actually  works  eight  and  a  half 
hours  plus  one  hour  for  class  work  three  times  a  week  for,  say,  eight  months  in  the 
year. 

There  is  during  these  hours  of  labor  a  constant  change  of  occupation,  a  constant 
shifting  from  one  piece  of  work  to  another.  It  is  not  a  hard  mental  work.  There 
are  a  good  many  recreation  hours,  and  the  nurse,  if  she  takes  care  of  herself,  or  is 
compelled  to  do  so,  has  a  good  deal  of  fresh  air,  and  there  is  no  good  reason  why  she 
should  not  remain  healthy  and  strong  and  active  mentally  and  physically. 

It  is  not  a  question  whether  the  three-shift  service  would  be  pleasanter  and  less 
arduous  for  the  pupil  nurse;  the  main  question  is,  is  the  two-shift  too  arduous,  too 
confining  for  the  pupils  to  stand?  The  contention  by  those  who  are  active  advo- 
cates of  the  three-shift  service  is  that  the  pupils  do  not  get  time  enough  to  study  their 
lessons,  and  that  they  are  too  tired  at  the  end  of  the  day  to  do  so  even  if  there  is 
time.  Perhaps  this  is  true.  Would  not  this  point  be  met,  however,  if  we  agreed  to 
teach  the  nurses  by  methods  that  would  necessitate  less  study  on  their  part,  and 
that  would  give  them  a  greater  insight  into  their  subjects  during  the  recitation  or 
lecture  hours;  in  other  words,  apply  the  object-lesson  method?  This,  of  course, 
takes  us  back  to  the  question  of  the  ability  of  lecturers  to  teach  as  well  as  to  lecture. 
There  are  many  men  and  women  who  can  conduct  a  class  in  any  given  subject,  so 
that  the  pupils  will  have  mastered  the  subject  at  the  end  of  the  hour,  whereas  another 
lecturer  will  merely  emphasize  the  necessity  for  the  pupils  to  go  home  and  get  their 
books  out  and  study  the  lesson.  In  the  public  schools  of  this  country  the  object- 
lesson  method  has  been  substituted  for  every  other  plan  in  the  teaching  of  small 
children  and  of  young  pupils  generally.  They  are  taught  by  reason  and  precept, 
example  and  illustration,  and  not  by  talk. 

However,  the  strongest  argument  against  the  three-shift  service  has  to  do  with 
the  patient  in  the  hospital.  There  are  two  shifts  in  sickness — a  day  and  a  night 
shift.  The  doctor  recognizes  these  two  shifts  in  the  condition  of  his  patient,  and, 
while  he  would  far  rather  the  same  nurse  remained  on  the  case  throughout  the 
twenty-four  hours,  he  will  always  regard  with  anxiety  and  misgiving  three  distinct 
changes  in  the  nursing  service,  and  the  consequent  loss  of  that  peculiarly  personal 
relationship  that  must  exist  between  patient  and  nurse  if  the  former  is  to  have  the 
greatest  possible  amount  of  watchfulness  and  care. 

Home  Life  of  Pupil  Nurses. — It  goes  without  saying  that  the  home  life  of  pupil 
nurses  in  the  training-school  ought  to  be  made  as  happy  and  pleasant  as  possible, 
just  as  the  home  life  of  every  young  woman  ought  to  be  made  happy  and  pleasant. 
For  many  of  these  young  women  the  three  years  of  their  training  are  about  all  the 
girlhood  they  have.  At  home  perhaps  the  social  and  financial  status  of  the 
family  has  compelled  them  to  work  hard,  to  live  within  narrow  limits,  perhaps  to 
help  younger  children,  and  some  of  them  have  worked  for  their  living  long  before 
they  came  into  the  training-school.  If  their  domestic  lives  in  the  school  are  well 
regulated  they  ought  to  have  good  times.  Their  hours  of  duty  ought  to  be  well 
mixed  with  hours  of  recreation.  They  ought  not  only  to  be  allowed  to  romp — 
they  ought  to  be  encouraged  to  do  so.  The  nurses'  home  that  has  a  gymnasium 
and  a  swimming  pool  will  be  almost  ideal.  A  piano  in  the  parlor,  and  the  greatest 
latitude  in  its  use,  will  help  to  while  away  many  a  lonesome  hour.  They  ought  to 
have  parties.  In  some  of  the  large  institutions  the  training-school  pupils  are 
given  a  party  every  month.  In  a  few  of  them  a  party  every  two  weeks  is  the 
rule — not  expensive,  formal  affairs,  but  an  informal  meeting  of  young  people,  girls 
and  boys,  during  which  there  is  dancing,  a  light  lunch,  perhaps  sandwiches  and 


THE    MODERN    TRAINED   NURSE  325 

coffee,  anil  a  lot  of  girlish  giggling  and  talk.  These  parties  wipe  away  almost  the 
whole  memory  of  sick-room  service,  the  long  vigils  of  the  night,  and  the  foot-sore 
trampings  of  the  day.  Who  ever  heard  of  a  pupil  nurse  whose  feet  did  not  hurt  all 
day  long,  and  whoever  heard  of  a  pupil  nurse  whose  sore  feet  interfered  with  her 
dancing  at  night? 

It  goes  without  saying  that  every  pupil  nurse  should  have  a  room  of  her  own, 
and  if  she  can  have  a  private  bath  so  much  the  better. 

Training-schools  are  not  exempt  from  those  epidemics  of  morbidity  that  so 
often  invade  convents  and  young  women's  academies  and  girls'  schools  of  every 
description.  One  morbid  pupil,  with  erotic  tendencies,  can  sometimes  pollute  a 
whole  training-school. 

Not  only  should  the  health  of  the  girls  individually  be  looked  after  carefully 
by  the  supervisor  of  the  nurses'  home,  but  the  health  of  the  home,  as  a  whole,  should 
be  regulated  by  proper  hygienic  and  sanitary  equipment  of  every  sort  for  the  occu- 
pants. It  is  not  enough  that  the  plumbing  and  ventilation  shall  be  right,  and  that 
the  pupils  shall  be  compelled  to  use  fresh  air  in  large  quantities,  but  the  supervisor 
should  act  in  the  capacity  of  a  mother  to  these  young  women,  so  many  of  whom, 
although  in  the  second  and  third  year  of  their  training,  have  not  the  slightest  idea 
of  how  to  take  care  of  themselves.  They  should  be  taught  to  keep  their  bowels  open, 
and  the  supervisor  should  see  that  they  do  so.  They  should  be  taught  to  protect 
themselves  before  and  during  their  menstrual  periods,  and  they  should  be  supplied 
with  proper  sanitary  appliances  for  use  at  that  time. 

A  good  many  of  the  pupils  in  the  training-schools  come  from  long  distances, 
and  have  no  social  acquaintances  at  distances  near  enough  for  daily  visits  and  recre- 
ation and  change  of  air  and  scene,  and  hence,  during  their  hours  off  each  day,  they 
sleep  or  read  some  trashy  book,  and  on  their  "half-day"  they  do  the  same,  and  when 
their  "whole  day"  comes  around  once  a  month  they  have  nothing  to  do,  no  place 
to  go,  no  incentive  to  change  their  environment,  and  hence  they  remain  in  the  home, 
fail  to  take  proper  exercise,  keep  constantly  to  the  old  mental  channels  of  thought, 
and  vegetate  mentally  and  physically.  This  sort  of  thing  is  not  natural  to  a  young 
girl,  and  if  she  is  encouraged  to  get  away  froms  the  home  to  go  on  little  excursions, 
to  go  to  inexpensive  places  of  amusement,  or  to  the  parks,  or  for  long  walks,  she 
will  soon  acquire  a  habit  of  doing  so,  and  will  be  a  far  better  pupil  and  a  healthier 
girl. 

In  the  section  on  Interns  we  have  considered  the  relationship  of  the  young 
men  to  the  pupil  nurses,  and  so  need  not  again  go  into  the  subject. 

Undergraduate  Specials. — In  almost  every  hospital  there  is  a  scarcity  of  nurses, 
and  this  will  happen  oftcner  in  small  hospitals  than  in  large,  for  the  reason  that  it 
is  more  difficult  for  small  hospitals  to  secure  an  acceptable  class  of  applicants, 
partly  because  of  the  limitations  in  the  training  that  the  young  women  will  get  in 
the  smaller  institution,  and  partly  because  the  work  of  nursing  in  small  institutions 
too  often  partakes  of  the  "maid-of-all-work"  character,  and  young  women  of  educa- 
tion and  refinement  do  not  like  this  sort  of  service,  hence,  they  will  seek  large 
hospitals  that  have  serving  maids  and  maids  of  all  work,  and  cleaner-  of  various 
sorts,  male  and  female,  and  male  orderlies,  so  that  the  nurse  can  do  actual  nursing, 
rather  than  a  multiplicity  of  things  that  teach  her  nothing  ami  that  are  mere 
drudgery. 

Some  of  the  heads  of  the  best  training-schools  in  the  country  do  not  take 
kindly  to  the  idea  of  placing  pupil  nurses  in  positions  as  undergraduate  specials 
on  cases  in  the  institution.  They  say,  and  with  a  good  deal  of  justification,  thai 
the  nurse  learns  very  little  under  such  circumstances,  that  if  there  were  very  much 


326  OPERATION    OF    THE    HOSPITAL 

to  do  of  a  technical  character  she  would  not  be  detailed  for  the  purpose  because 
she  would  not  be  qualified,  hence  she  would  learn  very  little  there  and  would  be 
losing  a  good  deal  of  her  training  in  directions  that  would  be  of  far  greater  value; 
that  if  there  is  very  much  to  do  of  competent  nursing  in  these  special  private-room 
cases  there  could  not  be  a  sufficient  amount  of  surveillance  of  pupil  nurses'  work 
to  make  that  work  of  any  value  to  her  in  her  training. 

They  say,  moreover,  that  the  pupil  is  giving  more  than  an  adequate  return  for 
the  time  and  expense  of  her  training  in  the  amount  of  work  she  does  on  the  wards 
and  in  the  routine  work  of  the  institution;  therefore,  it  is  unfair  to  ask  her  to  submit 
to  assignment  to  duties  that  are  wholly  in  the  interest  of  the  hospital  and  that 
have  to  do  with  the  institution's  financial  betterment  rather  than  the  pupil's 
training. 

There  is  another  side  of  this  question,  however;  nearly  all  institutions  have 
a  very  serious  financial  problem  to  face  constantly,  and  they  must  make  every  item 
and  every  factor  count  toward  meeting  their  financial  necessities — hospitals  are 
not  mercantile  institutions,  and  in  most  hospitals  it  is  considered  a  most  desirable 
condition  of  things  to  have  enough  pupil  nurses  to  use  some  of  them  as  special 
nurses  on  private  cases.  Generally  the  hospital  gets  S15  a  week,  more  or  less,  for 
the  services  of  these  undergraduates,  and,  while  perhaps  they  may  not  be  quite  so 
efficient  as  the  graduate  nurse,  who  will  oftentimes  have  to  be  brought  into  the 
institution  to  nurse  special  cases,  they  will  be  certainly  more  amenable  to  the 
discipline  of  the  institution,  and,  because  they  will  be  compelled  to  work  more 
strictly  under  the  direction  of  the  head  nurses  of  the  department,  it  is  a  very 
serious  question  whether  their  service  will  not  be,  after  all,  more  efficient,  so  far 
as  the  patient  and  the  physician  are  concerned.  As  a  rule,  undergraduate  specials 
are  chosen  for  each  individual  case,  and  there  need  not  be  a  rule  in  the  institution 
which  provides  that  undergraduate  specials  shall  be  of  the  senior  class.  Oftentimes 
there  is  almost  nothing  to  do  for  these  patients,  except  to  be  in  the  room.  Some- 
times they  will  require  the  simplest  sort  of  service,  a  service  that  a  probationer  can 
do  quite  as  well  as  a  more  advanced  pupil,  and  certainly  the  probationer,  being  of 
less  use  elsewhere,  can  be  better  spared  for  such  cases. 

It  is  the  easiest  thing  in  the  world  to  persuade  a  private-room  patient  in  a  hos- 
pital that  he  or  she  has  just  cause  for  complaint  about  something  in  the  service 
or  in  the  food,  and  it  is  a  well-known  fact  in  hospitals  where  graduate  specials 
are  employed  that  many  of  these  young  women  are  in  the  habit  oftentimes  of 
laying  the  burden  of  their  own  shortcomings  and  laziness  on  the  institution  itself. 
If  the  room  is  not  cleaned  properly  and  promptly  the  graduate  nurse  is  the  first 
one  to  complain  of  the  laxity  of  the  service  in  the  hospital,  and  when  this  com- 
plaint is  uttered  in  the  presence  of  her  patient  it  has  a  demoralizing  effect  on  the 
latter.  Of,  if  there  has  been  some  inattention  on  the  part  of  the  nurse  or  a  failure 
to  carry  out  some  order  that  the  patient  herself  has  heard  the  doctor  give,  the 
graduate  nurse  will  oftentimes  excuse  herself  on  the  ground  that  the  hospital 
refused  to  supply  her  with  the  necessary  material  to  carry  out  the  order.  And  so 
it  may  be  quite  safely  said  that  a  very  large  proportion  of  the  complaints  uttered 
by  patients  against  the  service  of  a  well-regulated  institution  are  either  instigated 
by  the  graduate  nurse  or  could  have  been  prevented  by  her.  On  the  other  hand, 
the  undergraduate,  being  herself  a  part  of  the  institution  and  its  administration, 
and  being  subject  to  the  discipline  of  the  training-school  and  her  superiors,  is  much 
more  likely,  first,  to  please  her  patient  by  every  possible  exertion  because  of  her 
discipline,  and  second,  to  minimize  aiiy  little  shortcoming  or  laxity  in  the  service 
rather  than  exaggerate  it;  so  that  the  hospital  administrators  generally  try,  as  far 


THK    MODERN    TRAINED    NURSE  '■'>-, 

as  possible,  to  furnish  undergraduate  specials  to  private  patients  rather  than  call 
graduates  from  private  duty  on  the  outside. 

In  most  of  the  large  institutions  graduate  special  nurses  feel  themselves  inde- 
pendent of  the  training-school  discipline,  refuse  to  be  bound  by  it,  oftentimes  resent 
any  interference,  and  hold  themselves  responsible  to  the  physician  alone.  It  is  to 
be  feared  that  sometimes  this  attitude  of  the  graduate  nurse  has  its  birth  in,  and 
is  fostered  by,  the  disinclination  to  be  responsible  for  her  acts  to  the  doctor  on 
the  case.  This  whole  attitude  of  the  graduate  nurse  is  to  be  greatly  deplored,  and 
seems  to  be  hastening  the  day  when  the  well-regulated  hospital  will  refuse  t<>  em- 
ploy outside  nurses,  or  to  allow  them  the  courtesies  of  the  institution  in  their 
professional  capacity,  because  of  their  growing  arrogance  in  almost  every  city  and 
every  institution. 

Considering  the  undergraduate  or  pupil  in  the  capacity  of  a  special  nurse, 
however,  we  are  confronted  by  a  responsibility  toward  the  pupil  that  it  seems  we 
do  not  weigh  quite  heavily  enough.  The  good  soldier  obeys  orders,  and  the  well- 
disciplined  pupil  nurse  goes  where  she  is  sent,  and  performs  her  duty  there  to  the 
best  of  her  ability,  and  remains,  like  a  picket  on  duty,  until  relieved.  Sometimes 
the  case  is  an  extremely  arduous  one,  that  requires  the  nurse  to  lose  an  immense 
amount  of  sleep,  and  to  be  on  her  feet  and  rustling  every  minute  of  the  time.  The 
good  nurse  does  not  complain;  consequently,  unless  the  heads  of  the  training- 
school  watch  very  carefully  the  service  of  the  undergraduate  special,  they  will  find 
their  pupil  is  being  overworked,  and  doing  day  and  night  duty  to  an  extent  that 
will  undermine  her  health.  Instances  have  been  known  where  a  pupil  nurse  was 
put  on  a  case  and  kept  there  on  twenty-four-hour  shifts  until  she  was  utterly 
broken  down  and  sent  off  sick.  Immediately  thereupon  two  graduate  specials 
have  been  required  to  do  the  same  work  the  unpaid,  overworked  pupil  nurse  had 
done  until  she  was  incapacitated;  it  ought  to  be  borne  in  mind,  therefore,  that 
very  great  care  must  be  taken  in  the  selection  of  patients  in  whose  cases  an  under- 
graduate special  may  be  employed,  to  see  that  the  work  is  either  arranged  in  double 
shift  and  two  pupil  nurses  employed,  or  to  see  that  ample  arrangements  for  relief 
are  made. 

The  Graduate  Special. — We  have  almost  covered  the  question  of  the  em- 
ployment of  graduate  nurses  within  the  institution,  but,  since  we  are  now  upon  the 
subject  of  nursing,  and,  therefore,  on  the  subject  of  the  training-school,  it  would 
seem  in  place  to  discuss  at  least  briefly  the  question  of  the  duties  of  graduate  nurses. 
We  have  argued  somewhat  against  the  principle  of  the  employment  of  graduate 
nurses  in  the  hospital,  and  the  reasons  have  been  given.  Sometimes,  however,  it 
will  become  necessary,  either  because  of  scarcity  of  nurses  in  the  training-school 
or  because  of  insistence  on  the  part  of  patients  or  their  friends  or  the  physician,  to 
bring  in  a  graduate  nurse.  In  most  institutions  where  this  is  done,  and  it  is  done  al- 
most everywhere,  the  graduate  nurse  comes  in  and  takes  charge  of  her  patient  with 
a  chip  on  her  shoulder,  so  to  speak,  resenting  interference  at  every  point,  and 
reserving  the  right  to  ride  over  rough  shod  the  rules  of  the  institution  appertaining 
to  everybody.  If  the  institution  discipline  and  administrative  Functions  of  the 
hospital  alone  were  disturbed  by  this  attitude  it  might  not  be  quite  unbearable,  but 
these  are  the  least  of  the  difficulties.  Most  graduate  nurses  forget  a  good  deal  of 
their  training  after  they  have  left  the  hospital  a  short  time,  and  no  longer  are  mis- 
tresses of  the  technic  of  the  institution  and  its  ways  of  doing  things:  therefore 
they  become  unfamiliar  with  apparatus  and  instruments,  and  they  are  disposed  to 
call  for  new  things,  and  they  even  attempt  to  disturb  the  technic  of  the  institution 
and  to  revolutionize  wherever  they  may;  and  sometimes,  where  they  are  not  per- 


328  OPERATION    OF   THE    HOSPITAL 

mitted  to  do  so,  they  will  succeed  in  arraying  the  patient,  the  patient's  friends, 
and  even  the  physician  against  the  methods  and  procedure  of  the  institution,  and 
we  next  hear  the  complaint  that  there  is  too  much  red  tape  employed,  and  that, 
therefore,  the  patient  suffers  for  want  of  proper  and  prompt  attention.  Without 
doubt,  most  of  these  graduate  nurses  are  loyal  to  the  institution  because  they  are 
graduates  of  it  and  because  their  friends  work  there,  and  because  the  institution 
helps  them  to  get  private  cases,  so  that  we  may  safely  assume  that  it  is  merely 
want  of  tact  that  makes  them  unruly  and  apparently  disloyal. 

There  is  a  cure  for  this,  and  that  is  to  have  a  code  of  rules  for  graduate  nurses 
on  duty  in  the  institution  that  must  be  inviolably  lived  up  to  and  infractions 
punished  by  dismissal;  and,  since  hospital  berths  are  most  attractive  to  most 
graduate  nurses,  if  they  are  given  distinctly  to  understand,  and  if  there  have  been 
a  few  illustrations  to  emphasize  the  fact  that  they  will  be  dismissed  from  the 
institution  if  they  do  not  obey  its  rules,  there  will  presently  come  a  pretty  well 
understood  relation  between  the  institution  and  the  graduate  nurses. 

Sometimes  the  heads  of  the  training-school,  who  are  responsible  for  the  execu- 
tion of  these  rules,  will  excuse  want  of  obedience  by  the  statement  that  they  cannot 
afford  to  drive  away  the  graduate  nurses  who  condescend  to  perform  service  there. 
A  little  reflection,  however,  and  a  little  inquiry  into  the  attractiveness  of  institu- 
tion service  from  the  standpoint  of  the  graduate  nurses  will  reassure  us  on  this 
point,  and  in  some  places,  where  a  strong  stand  has  been  made,  and  where  these 
young  women  have  been  compelled  to  obey  rules,  even  they  themselves  presently 
admit  the  advantage  of  the  rules  and  the  betterment  of  the  service  because  of  them. 
Perhaps  first  among  these  rules  is  a  provision  that  the  graduate  nurse  shall  work 
under  the  general  supervision  of  the  head  nurse  of  the  department.  This  is  the 
most  difficult  of  all  rules  to  enforce,  and  it  is  the  one  above  all  others  that  needs 
enforcing,  primarily  for  the  good  of  the  patient  and  in  the  interest  of  the  execution 
of  proper  orders. 

It  may  be  noted  that  very  few  institutions  work  under  definite  printed  rules 
for  graduate  nurses,  and  it  may  not  be  out  of  place,  therefore,  if  we  subjoin  some 
that  are  in  use  in  at  least  a  few  of  the  institutions  of  this  country: 

Rules   for   Graduate   Nurses 

Immediately  upon  entering  the  hospital,  the  graduate  nurse  who  has  been  called  for  a  case 
will  report  to  the  superintendent  of  the  training-school  for  orders  concerning  the  patient. 

Graduate  nurses  will  wear  their  full  uniforms  when  on  duty  in  the  hospital. 

Graduate  nurses  will  wear  rubber  heels  in  the  hospital,  and  will  not  be  permitted  to  go  on 
duty  without  them. 

Graduate  nurses,  when  leaving  the  room  of  the  patient  at  night,  will  be  dressed  sufficiently 
to  appear  in  public. 

The  graduate  nurse  will  be  required  to  carry  meals  from  the  serving  room  to  her  patient,  and 
to  return  the  used  tray  promptly  after  the  meal  is  over.  She  will  be  required  to  wash  whatever 
dishes  or  utensils  she  has  occasion  to  use,  excepting  for  the  regular  meals,  and  to  return  them  to 
their  proper  places  on  the  shelves. 

Private  rooms  are  swept  and  dusted  once  daily,  and  rugs  are  cleaned  as  often  as  necessary; 
the  nurse  will  be  expected  to  otherwise  keep  her  patient's  room  in  a  clean  and  orderly  condition. 

It  is  an  important  part  of  the  duty  of  the  graduate  nurse  to  make  her  patient  comfortable 
mentally  as  well  as  physically,  and  to  see  that  patient,  relatives,  and  friends  are  pleased  with  the 
institution  and  its  service. 

The  graduate  nurse  is  understood  to  have  entered  the  service  of  nursing  in  the  hospital  with 
a  full  knowledge  of  its  rules  in  all  departments,  and  of  the  technic  of  all  nursing  procedure,  and 
to  have  accepted  the  responsibility  of  conforming  to  them.  She  will  nurse  her  patient  according 
to  the  methods  of  the  institution  in  all  details. 

The  graduate  nurse  will  take  orders  for  her  patient  from  the  medical  attendant  in  the  case 
or  from  the  intern  on  the  service;  if,  for  any  reason,  the  orders  cannot  be  carried  out  precisely  as 
given,  she  will  immediately  communicate  with  the  intern,  or,  failing  to  reach  him,  with  the 
attending  physician,  to  have  the  orders  changed.     If  she  cannot  reach  one  of  the  responsible 


THE    MODERN    TRAINED    NURSE  329 

physicians  she  will  lay  the  difficulty  before  the  nurse  in  charge  of  the  floor  or  ward  or  the  super- 
intendent, and  thus  place  responsibility  whore  it  belongs,  whether  on  the  physicians  or  cm  1 1  n  - 
nursing  representatives  of  the  hospital, 

Graduate  nurses  on  duty  in  the  hospital  are  expressly  forbidden  to  eat  in  their  patients'  rooms, 
or  to  order  any  food  whatever  except  inn  for  their  patients'  own  use. 

Graduate  nurses  will  not  be  permitted  to  visit  in  any  part  of  the  hospital  excepting  where 
their  duty  lies,  excepting  with  the  explicit  consent  of  the  superintendent,  of  the  training-school 
in  each  instance. 

Graduate  nurses  will  be  expected  to  report  all  breakages  and  damage  to  hospital  property 
immediately  on  their  occurrence,  and  to  pay  for  same  unless  payment  is  expressly  waived  by  the 
superintendent  of  the  hospital  in  each  case.  Failure  or  refusal  to  pay  for  same  on  demand  will 
subject  the  offender  to  immediate  dismissal  from  the  institution,  and  she  will  not  again  be  per- 
mitted to  nurse  in  the  hospital  until  the  amount,  has  been  paid. 

The  hospital  declines  to  collect  fees  for  graduate  nurses,  and  will  under  no  condition  assume 
any  responsibility  for  same.  The  institution  business  office  will  at  any  time  be  pleased  to  give  the 
special  nurse  any  information  in  its  possession  concerning  the  financial  responsibility  of  her 
patient,  but  declines  to  be  held  responsible  for  the  correctness  of  said  information. 

The  hospital,  as  an  accommodation,  provides  board  for  graduate  special  nurses  on  duty 
there,  charging  the  actual  cost  of  same  against  her  patient,  but  the  institution  will,  under  no  con- 
ditions, undertake  to  furnish  special  diet  for  nurses  on  duty. 

Repeated  or  flagrant  violation  of  these  rules  will  subject  the  offender  to  dismissal  and  to  refusal 
of  further  employment  in  the  institution. 

Graduate  Nurses  in  Private  Practice. — We  enter  upon  very  briefly  here  the 
contemplation  of  a  situation  which  may  be  characterized  as  very  little  short  of  dis- 
graceful. We  are  all  of  us  busy  training  pupil  nurses  to  be  efficient,  intelligent,  obe- 
dient caretakers  of  the  sick,  with  the  intention  that  as  soon  as  they  are  fitted  for 
this  work  they  shall  be  clothed  with  proper  authority  as  certified  in  their  diplomas. 
We  have  a  right  to  assume  when  a  nurse  leaves  the  institution  with  her  diploma 
in  her  hand  that  she  is  going  to  make  herself  useful  to  sick  people,  and  we  uphold 
her  in  certain  demands  that,  on  the  whole,  bespeak  for  her  a  position  of  dignity  and 
importance,  one  well  up  in  the  social  scale,  and  one  in  which  she  will  not  be  bur- 
dened with  overwork.  In  return,  we  ask  of  her  the  performance  of  certain  duties 
in  an  acceptable  maimer,  and  those  duties  have  to  do  with  the  sick  person,  with  the 
family  and  friends  of  the  sick,  with  the  physician  who  is  responsible  for  the  care  of 
the  sick,  and  with  the  public  at  large.  The  term  disgraceful,  as  applied  to  the  situa- 
tion in  this  country,  is  justified  by  the  unquestioned  fact  that  graduate  nurses,  as 
a  class,  are  not  living  up  to  the  expectations  either  of  the  public,  the  physician, 
the  patient,  or  the  schools  that  sent  them  out. 

Let  us  see  briefly  wherein  lies  the  failure :  in  the  first  place,  the  home  to  which  the 
graduate  nurse  is  called  is  in  a  turmoil;  some  one  is  ill,  the  family  is  anxious  and 
in  trouble,  things  generally  are  at  sixes  and  sevens,  the  servants  have  no  mistress; 
the  housekeeping  duties  are  neglected,  the  meals  probably  irregular;  the  servants 
are  asked  to  serve  one  or  two  members  of  the  family  at  a  time,  and,  therefore, 
the  meals  are  strung  out  almost  through  the  day.  The  servants,  being  rather  an 
ignorant  and  consequently  narrow-minded  lot,  become  impatient  and  dissatisfied, 
and  they  talk  about  leaving,  even  if  they  do  not  go  so  far  as  to  actually  quit  tin- 
service  of  a  family  that  lias  already  trouble  enough.  Now,  the  graduate  nurse 
comes  on  the  scene.  Would  it  not  seem  that  a  part  of  her  duty,  after  she  gives  her 
immediate  attention  to  the  sick  person,  is  to  help  make  things  comfortable  and 
pleasant  in  the  home  itself,  to  make  as  little  trouble  as  possible,  to  go  about  her 
duties  without  friction  with  the  servants,  to  make  few  demands  of  a  personal  nature. 
and  to  content  herself  witli  what  is  in  sight? 

Will  any  of  us  dare  to  say  f  hat  t  his  is  the  common  attitude  of  the  graduate  nurse? 
It  is  not  the  experience  of  most  of  us.  If  we  ask  ten  people  who  have  had  graduate 
nurses  in  their  families  during  the  past  year,  nine  of  them  will  agree  that  the  nurse 
required  more  waiting  upon  and  more  personal  service  than  the  sick  person;   that 


330  OPERATION    OF   THE    HOSPITAL 

she  made  demands  that  were  oftentimes  practically  impossible  to  gratify;  that  her 
first  thought  was  for  herself  and  her  personal  comfort,  for  her  meals,  and  for  her  sleep- 
ing accommodations,  for  her  laundry,  and  so  on,  down  a  long  list  of  outrageous 
demands. 

Fortunately,  there  is  another  side  to  this  picture,  and  all  of  us  have  personal 
knowledge  of  a  number  of  graduate  nurses  and  their  methods,  who  bring  to  their 
duties  an  unselfish  devotion,  a  tact  and  thoughtfulness  worthy  a  better  reception. 
There  are  some  women  and  men,  too,  who  employ  graduate  nurses,  and  who  at  once 
set  them  in  a  class  with  the  cook  and  the  laundress;  who  exact  of  them  the  most  me- 
nial service  of  a  personal  nature;  who  work  them  day  and  night,  not  only  in  the  care 
of  the  sick  for  whom  they  were  employed,  but  in  a  personal  service  for  well  members 
of  the  family. 

To  illustrate  what  a  graduate  nurse  in  a  house  of  trouble  should  be:  she  steps 
soft-footed  into  the  house  of  sickness,  she  takes  with  her  a  cheery  smile,  a  modulated 
voice,  and  an  animated  demeanor.  She  goes  about  the  house  getting  what  she 
needs  for  her  patient.  If  she  cannot  find  precisely  what  is  wanted,  she  will  often- 
times make  something  else  do.  She  will  make  friends  with  the  servants,  and,  after 
an  hour,  sometimes  will  have  them  on  her  staff  working  disinterestedly  with  her 
toward  a  common  end.  Oftentimes,  and  by  easy  stages,  she  will  unobtrusively  take 
over  the  duties  of  the  housekeeping,  sometimes  even  to  the  extent  of  ordering  the 
meals.  She  will  provide  little  comforts  and  pleasant  surprises  for  the  grief-stricken 
mother,  perhaps,  and  so  by  her  good  offices  render  her  presence  in  the  home  a  dis- 
tinct blessing,  rather  than  tolerated  as  a  necessary  evil. 

Without  any  question,  this  disagreeable  attitude  of  the  average  graduate  nurse 
in  private  practice,  when  it  exists,  is  the  fault  of  bad  training.  In  the  curriculum  of 
nearly  every  training-school  there  may  be  found  a  course  of  lectures  on  the  "ethics 
of  nursing,"  and  it  will  be  found  of  intense  interest  to  those  of  us  who  are  actively 
interested  in  nursing  problems,  if  we  were  to  listen  to  one  of  these  lectures  or  read 
one  of  them  that  attained  the  dignity  of  publication.  When  we  know  what  these 
lectures  contemplate,  as  a  rule,  we  will  have  very  little  difficulty  in  judging  the  cause 
of  poor  nursing,  poor  judgment,  and  want  of  tact  in  the  modern  graduate  nurse. 

There  is  a  cure  for  this,  and  that  cure  must  be  administered  in  the  training- 
school,  and  it  must  take  the  form  of  definite  teaching  of  the  domestic  virtues,  of 
tact  in  the  attitude  of  the  nurse  toward  her  patient  and  the  people  who  surround  the 
patient.  A  lecture  on  ethics  will  not  do  it;  it  must  be  a  constant  drilling;  it  must 
be  a  drilling  on  the  wards  of  the  institution,  in  the  private  rooms  of  patients  there, 
in  the  conduct  of  the  pupil  nurse  toward  her  comrades  and  co-workers  in  the 
hospital. 

The  Nursing  Profession  and  the  Public. — The  earnest,  thinking  friends  of  the 
nursing  profession  look  with  a  good  deal  of  apprehension  upon  the  tendency  of 
present-day  methods  in  the  profession  that  seemingly  have  for  their  object  the  es- 
tablishment of  principles  on  the  lines  of  labor  unions. 

In  all  other  professions — that  is,  medicine,  law,  engineering,  and  art — it  has  long 
become  an  established  principle  that  there  can  be  no  fixed  prices  for  professional 
services  independent  of  the  conditions  in  each  case;  and  those  of  us  who  are  anxious 
to  see  the  profession  of  nursing  established  on  a  high  plane  feel  the  same  way  about 
that  profession.  Just  how  far  we  may  go  in  this  direction  it  is  difficult  to  say,  but 
those  of  us  who  share  the  fear  that  the  nursing  profession  may  be  brought  down 
rather  than  lifted  up  by  the  inculcation  of  union  labor  principles,  are  looking  toward 
the  nursing  commissions  of  the  several  states,  that  have  been  recently  established 
under  new  laws,  for  a  solution  of  this  much  discussed  question. 


THE    MODERN'    TRAINED    NURSE  331 

Nearly  every  state  in  the  Union  now  has  a  nursing  law,  and  they  are  pretty 
uniform,  taken  altogether.  They  differ,  of  course,  in  details,  but  they  follow  the 
same .  general  principles.  In  some  states  the  commission,  usually  appointed  by  the 
governor,  is  made  up  wholly  of  nurses.  In  other  states,  such,  for  instance,  as 
Pennsylvania,  the  nursing  commission  is  made  up  of  physicians  and  nurses. 
And,  yet  again,  in  a  few  states  there  is  a  small  admixture  of  influence  outside  both 
these  professions  by  the  appointment  of  some  public-spirited  citizen,  who  has  taken 
a  particular  interest  in  nursing  as  a  profession.  In  some  of  the  states  these  com- 
missions have  risen  to  a  high  plane,  and  have  fine  aspirations  for  the  profession. 
In  other  states  there  is  a  definite  trend  toward  the  principles  of  union  labor. 

Without  any  question,  time  will  smooth  out  many  of  the  rough  places,  and  it 
is  to  be  hoped  that  wise  counsel  in  the  leadership  of  the  profession  of  nursing  will 
set  that  profession  beyond  the  sordid  things  that  have  their  whole  expression  in 
a  fixed  rate  of  pay  per  day  for  the  trained  nurse,  irrespective  of  her  qualifications  or 
previous  education  and  her  power  for  initiative.  The  state  nursing  commissions 
have  hardly  gone  far  enough  with  their  work  as  yet  to  be  fairly  judged  as  to  what 
the  future  will  bring,  and  some  of  them  that  seem  to  have  been  going  in  a  dangerous 
direction  will  undoubtedly  see  their  mistakes  and  correct  them. 

For  instance,  in  some  of  the  states  the  nursing  commissions  have  prescribed 
a  curriculum  for  the  training-schools  that  goes  very  far  beyond  the  capacity  of 
women  who  are  obtainable  to  enter  these  training  schools.  Of  course  this  practice 
must  eventuate  in  badly  trained  nurses,  just  as  any  one  in  any  calling  will  be  badly 
trained  who  is  asked  to  prosecute  his  or  her  training  far  beyond  the  mental  capac- 
ity of  the  individual.  This,  too,  will  be  smoothed  out  in  time.  And  even  the 
qualifications  for  entrance  to  the  training-schools  will  be  set  upon  a  different  plane, 
or  the  curriculum  established  by  the  state  commissions  will  be  modified  to  meet  the 
practical  necessities  of  the  case. 

In  this  modern  day  the  trained  nurse  is  a  necessity,  not  a  luxury.  Fortunately, 
the  people  are  finding  it  desirable  to  go  to  the  hospitals  when  they  require  technical 
care,  and  this  will  come  to  be  the  case  more  and  more  every  year,  until  presently  it 
will  be  considered  a  matter  of  course  that  the  man,  woman,  or  child  who  is  sick,  from 
whatever  cause  or  with  whatever  ailment,  shall  go  to  the  hospital,  but  until  that 
comes  the  sick  must  be  nursed  at  home  under  certain  conditions,  and  there  must 
be  nurses  to  take  care  of  them.  A  goodly  part  of  this  work  is  done  now  by  visiting 
nurses  employed  by  associations  of  various  sorts,  and  the  visiting  nurse  is  another 
expression  directly  from  the  public  that  the  average  individual  at  home  cannot 
afford  to  pay  the  price  of  a  trained  nurse,  and,  therefore,  the  community  is  being 
asked  to  pay  for  the  trained  nurse. 

A  very  large  percentage  of  the  cases  of  illness  that  remain  at  home  to  be  cared 
for  need  very  little  or  no  technical  attention,  and  in  a  great  majority  of  these  cases 
the  people  cannot  afford  to  pay  a  trained  nurse.  The  question  is.  What  is  to  lie 
done  about  it?  Are  they  to  have  trained  attention  withheld  from  them  because 
they  cannot  afford  to  pay  the  schedule  price?  This  is  quite  satisfactorily  settled 
in  the  medical  profession,  because  it  is  uniformly  recognized  that  physicians  must 
base  their  professional  charges  upon  the  ability  of  the  patient  to  pay  and  nut  upon 
the  value  of  the  service,  without  any  other  condition  than  the  doctor's  ordinary 
charges.  We  all  know  very  well  that  the  ablest  men  in  the  medical  profession, 
both  those  in  general  practice  and  those  restricting  themselves  to  the  special  branches 
of  medicine,  do  an  immense  amount  of  work  at  vastly  reduced  prices,  in  addition, 
of  course,  to  what  they  do  entirely  free.  This  principle  of  "tempering  the  wind  to 
the  shorn  lamb"  is  so  thoroughly  understood  in  the  medical  profession  that  we 


332  OPEKATION    OF   THE    HOSPITAL 

need  not  dwell  on  it,  and  it  is  understood  quite  as  well,  too,  that  the  doctor  has  a 
right  to  charge  more  than  his  ordinary  fee  to  the  patient  who  can  abundantly  afford 
more,  and  the  patients  themselves  recognize  this  condition  of  affairs,  and,  as  a  rule, 
acquiesce  in  it. 

Is  it  not  possible  to  place  the  nursing  profession  on  some  such  plane  as  this? 
Of  course,  there  is  the  difference  that  the  nurse  must  give  her  whole  time  to  one 
patient,  and  that  she  cannot  be  earning  money  elsewhere  while  she  is  on  that  case. 
Then,  shall  we  permit  her  to  charge  more  on  the  next  case  where  the  people  can  afford 
to  pay  more,  or  shall  we  detail,  to  take  care  of  the  patient,  the  nurse  of  mediocre 
attainments,  one,  perhaps,  not  at  all  popular  with  the  doctors  in  her  sphere,  but 
who  is  recognized  as  a  conscientious,  painstaking  nurse? 

We  know  there  is  as  much  difference  between  the  ability  of  nurses  as  between 
doctors  or  lawyers,  and  it  is  never  expected  that  the  doctor  of  mediocre  attain- 
ments and  limited  education  shall  earn  as  much  money  or  receive  as  high  honors 
as  the  man  of  extraordinary  ability;  and  does  not  all  this  bring  us  back  again  to 
the  question,  Whether  we  shall  not  have  grades  of  trained  nurses  whose  diplomas 
from  their  schools  and  whose  licenses  from  their  states  shall  prescribe  precisely 
the  character  of  work  they  may  or  may  not  do? 

THE    CURRICULUM 

Schedule  for  First  or  Junior  Year 

First  year  pupils  are  divided  into  divisions  according  to  the  number  in  the  class,  and  with- 
out reference  to  the  probationary  period,  each  division  taking  the  same  work  at  different  hours 
and  under  the  same  teachers;  it  would  seem  expedient  to  put  the  brighter  or  better  educated  girls 
together,  and  those  less  favored  together. 

Dietetics  (this  work  is  given  in  the  diet  kitchen  in  actual  work  of  cooking  for  patients,  and  in 
lectures  by  the  dietitian) : 

1.  Foods — marketing  and  care  of  foods. 

2.  Classification  of  foods  chemically. 

3.  Character  of  food  constituents,  proteins,  fats,  carbohydrates,  etc. 

4-6.  Physiology  of  the  digestion — describe  the  alimentary  canal,  juices  along  its  course, 

and  functions  of  each,  beginning  with  the  mouth. 
7,  8.  Chemic  and  physiologic  values  of  specific  food  articles. 
9,  10.  Metabolism — what  becomes  of  the  food  and  how  it  is  distributed  to  the  tissues  as 
nutriment. 
11,  12.  Waste — what  is  wasted  and  what  becomes  of  it. 

_  Note. — These  lectures  may  be  contracted  into  fewer  or  more  lectures,  according  to  the  time  at 
disposal  and  the  abilities  of  the  classes. 

Household  Economics: 

1-3.  Relative  value  and  uses  of  household  materials  and  their  care. 
4,  5.  Furnishing  a  house;  furnishing  a  room;  furnishing  a  sick  room. 

6.  Ventilation  in  the  home,  in  the  hospital,  in  the  sick  room. 

7.  Plumbing  and  drainage — the  care  of  sinks,  basins,  toilets. 

8.  The  disposal  and  destruction  of  infectious  excreta. 

9,  10.  Linens — purchase  and  test  of  cloths;  care  of  linen  and  cotton  goods.     Making  up  hos- 
pital pieces. 
11,  12.  The  laundry — how  to  wash  and  clean  wool  and  cotton  goods,  blankets,  flannels,  curtain 
cloth,  and  the  rougher  wash  goods. 

Note. — Part  of  this  period  should  be  spent  in  the  linen  and  supply  rooms  at  mending,  sorting, 
distributing,  and  making  up  supplies. 

Surgical  and  Medical  Supplies: 

1-5.  Use  and  care  of  material — bedside  utensils,  bed  furnishings,  rubber  goods,  enameled 
ware,  etc.     Cleaning  and  sterilization. 
6-10.  Surgical  dressings  and  material — bandages. 

Surgery:  Surgical  dressings. 
1-5.  Surgical  dressings. 
6-10.  Bandaging. 


THE    MODERN   TRAINED    NURSE  333 

,•1  natomy  and  Physiology  (12  lectures  with  manikin  or  plates,  on  the  chief  organs  of  the  body,  with 
physiology  of  each): 

1.  Brain  and  spinal  cord  and  nervous  system. 

2.  Thorax  and  diaphragm. 

3.  Heart. 

4.  Lungs. 

5.  Abdomen  and  peritoneum. 

6.  Stomach. 

7.  Intestines,  small  and  large. 

8.  Liver. 

9.  Spleen  and  pancreas. 

10.  Kidneys  and  adnexa. 

11,  12.  Bladder  and  lower  urinary  tract — genitals. 

Materia  Mcdica  (10  lectures  and  demonstrations — the  principle  families  of  medicine,  the  commoner 
forms  of  administration,  physical  and  physiologic  character  of  each,  and  dosage). 
Note. — Details  of  this  subject  must  be  loft  to  the  teacher,  unless  some  primary  text-book  is 

followed. 

Pathology  and  Bacteriology  (15  lectures  in  the  laboratory,  illustrating  and  demonstrating  the 
pathogenic  and  non-pathogenic  micro-organisms;  the  fundamentals  of  asepsis  and  antisepsis). 
Note. — All  the  groups  will  have  demonstrations  in  bedside  nursing,  the  use  and  handling 
of  bed-pans,  urinals,  head  and  back  rests,  lifting  and  moving  patients;  use  and  care  of  rubber 
goods,  water-bags,  ice-bags,  rubber  tubes,  catheters,  stomach-tubes,  etc.,  the  giving  of  enemas, 
high  and  low,  irrigations,  care  and  use  of  percolators,  dressing  cars,  etc. 

Second  Year 
Dietetics  (practical  repetition  of  first  year's  work,  with  more  detail  in  making  up  of  special  diets 
for  certain  classes  of  patients,  diabetics,  etc.      This  work  will  be  in  the  diet  kitchen  and  in 
lectures,  the  number  of  which  will  depend  on  the  time  allowance.     Caloric  and  chemic 
calculations  of  foods  will  be  taught  at  this  time). 

Medicine: 

1.  The  keeping  of  records,  taking  temperatures,  pulse,  respiration,  and  why. 
2,  3.  Importance  of  little  things  in  records:  vomiting,  nausea,  chills,  body  movements,  like 
tossing  head,  etc.,  rolling  eyes,  gritting  teeth,  lapses  into  delirium,  spasms,  general 
or  local;  character  of  bowel  movements  and  peculiarities  of  same  with  significance. 
4-6.  The  eruptive  fevers,  their  differential  diagnosis  and  fundamentals  in  treatment. 

7,  8.  The  acute  fevers,  pneumonia,  typhoid — principals  underlying  their  care. 

9,  10.  Arteriosclerosis — chronic  interstitial  nephritis  and  complications — Bright's  disease. 

11.  Diseases  of  the  digestive  organs,  gastric  disorders,  diarrhea,  dysentery,  constipation. 

12.  Diseases  of  other  abdominal  organs — liver,  spleen,  kidneys,  pancreas,  the  enteroptoses. 
13,  14.  Tuberculosis — pulmonary — elsewhere. 

Anatomy: 

1.  The  bony  frame — its  physical  properties  and  uses — its  physiologic  properties. 

2.  The  bones  of  the  skeleton — their  divisions — the  long  bones — the  flat  bones — the  round 

bones. 

3.  The  bony  cavities — what  each  contains — Nature's  protective  devices. 

4.  The  brain  and  cord — functions — major  divisions. 

5.  Throat — pharynx — larynx. 

6,  7.  Thorax — heart,  lungs,  pleura,  diaphragm — relations  and  gross  functions. 

8,  9.  The  abdomen — stomach  and  intestines;  liver,  spleen,  kidneys  and  ureters,  pancreas, 

ovaries — their  relations  and  location. 
10,  11.  The  pelvis — bladder,  uterus,  rectum,  and  genitals. 

12.  The  muscles  of  the  body — flexors,  extensors,  physical  properties — direction  of  their  ac- 
tion in  relation  to  origin  and  insertion. 
Physiology: 

1.  The  circulation  of  the  blood  and  its  functions. 

2.  The  functions  of  the  brain  and  cord. 

3.  The  functions  of  the  heart. 

4.  The  functions  of  the  lungs. 

5.  The  functions  of  the  stomach  and  intestines. 

6.  The  functions  of  the  liver,  spleen,  pancreas,  kidneys,  and  skin. 

7.  The  generative  apparatus — male. 
S.  The  generative  apparatus — female. 

9.  The  sympathetic  and  general  nervous  system. 

10.  Organs  of  special  sense — eye. 

11.  The  car. 

12.  The  Dose. 


334  OPERATION    OF   THE    HOSPITAL 

Surgery: 

1.  Fractures  and  dislocations — treatment. 

2.  Wounds  of  soft  tissue:  incisions;  contusions,  lacerations,  burns  and  frost  bites;  treat- 

ment; processes  of  repair. 
3-5.  The  classical  surgical  operations. 

6.  Orthopedic  surgery:  aims  and  fundamentals. 

7.  Corrective  or  plastic  surgery. 

8-10.  Surgical  preparations:  asepsis  and  antisepsis. 

Pathology  and  Bacteriology: 

1.  Urinalysis. 

2.  Inflammation:  elementary  pathology  of. 

3.  Tumors:  varieties  and  peculiarities  of  each. 

4.  The  micro-organisms:  classes  and  peculiarities. 

5.  The  non-pathogenic  bacteria. 

6.  The  pathogenic  bacteria:  streptococcus,  erysipelas,  three  forms,  staphylococcus,  pneu- 

mococcus,  tubercle  bacillus;  the  spore-formers. 

7.  The  processes  and  methods  of  infection. 

8-11.  The  vaccines  and  serums — their  processes  of  operation  and  methods  of  employment; 
immunity. 

12.  Use  of  blood-counters. 

13.  Use  of  hemoglobinometer. 

14.  Use  of  blood-pressure  apparatus. 

Third  Year 
Dietetics  (diet  kitchen  work,  especially  as  to  special  diets  and  feeding  values,  10  lectures). 

11.  Milk:  chemistry  and  physiology  of  milk. 

12.  Pasteurization  and  sterilization  of  milk. 

13.  Formula;  and  compounds. 

14.  Feeding  values  of  various  milk  combinations. 

Obstetrics: 

1.  Pregnancy:  process  of  ovulation  and  fecundation. 

2.  Signs  of  normal  and  abnormal  pregnancy. 

3.  Complications  of  pregnancy:  abortion,  miscarriage,  and  eclampsia.     The  vomiting  of 

pregnancy. 

4.  Labor — the  phenomena  of:  stages,  presentations. 

5.  Accidents  of  labor. 

6.  Abnormalities  of  pregnancy:  anatomic  malformations. 

7.  Abnormal  labor.     Forceps  and  their  indications;  placenta  prsevia;  prolapse  of  cord; 

Cesarean  section. 
8-10.  Care  of  the  newborn  child:  emergencies. 
11,  12.  Care  of  the  postpartum  mother:  genitalia,  breasts,  bowels,  food. 

Infants  and  Young  Children: 

1,  2.  Anatomic  and  physiologic  peculiarities  of  the  infant. 

3,  4.  Inherited  abnormalities:  bony  malformations;  club-foot,  rickets;  skull  deformities; 

cross-eyes,  skin  lesions;  birthmarks. 
5,  6.  Care  of  the  newborn  and  premature  infant. 
7,  8.  Infant  feeding:  breast  and  artificial. 
9.  Faults  of  digestion  and  improper  feeding. 
10,  11.  Malnutrition:  gastro-intestinal  disorders;  summer  complaint. 

12.  Ordinary  diseases  of  childhood. 

13.  Exanthemata:  diphtheria,  whooping-cough. 

14.  Hygiene  and  care  of  the  healthy  child. 

Nervous,  Mental,  and  Special  Diseases: 

1.  Care  of  the  insane. 

2.  Care  of  "rest  cures." 

3.  Nervous  complications  of  medical  cases. 

4.  Care  of  skin  cases. 

5.  Care  of  diseases  of  the  eye,  ear,  nose,  and  throat 

6.  Hygiene  and  preventive  care  of  tuberculosis. 


THE    MODERN    TRAINED    NURSE  335 

MALE  NURSES 

Those  of  us  who  practised  medicine,  or  directed  the  affairs  of  hospitals,  under 
the  old  regime,  when  the  trained  woman  nurse  was  unknown,  and  when  the  male 
nurse  was  a  composite  of  drunkenness  and  genius,  wonder  whether  the  change  that 
has  wholly  eliminated  the  trained  male  nurse  is  for  the  best.  There  is  no  doubt 
that  there  is  something  stronger,  more  virile,  more  substantial,  and  certainly  less 
finnicky  in  the  male  nurse  than  in  the  female.  That  tender  touch  that  we  are  ac- 
customed to  sentimentalize  about,  that  human  sympathy  that  we  are  accustomed 
to  associate  with  femininity,  finds  almost  no  resting  place  in  the  institution  young 
woman  nurse  of  to-day.  Many  times  she  is  quite  as  heartless  as  the  most  heart- 
less of  the  opposite  sex.  Oftentimes  she  is  not  more  conscientious.  Almost  always 
she  is  subject  to  whims.  She  must  be  accorded  more  consideration,  at  the  expense 
sometimes  of  the  patient. 

On  the  other  hand,  the  male  nurse  has  usually  some  overpowering  failing,  some 
inherent  weakness,  that  forbids  his  success  in  any  permanent  line  of  human  endeavor. 
In  other  words,  the  male  nurse  has  been  nearly  always  "a  failure."  Many  times 
he  has  become  a  periodical  drunkard.  Sometimes  he  has  been  a  bright  young  busi- 
ness man  or  mechanic  or  clerk,  whose  intemperate  habits  have  brought  him  to  the 
hospital,  and,  after  repeated  trials  and  repeated  failures,  he  has  found  that  his  only 
safety  lies  in  shutting  himself  out  from  the  world,  and  subjecting  himself  to  the 
discipline  of  the  hospital  or  the  eleemosynary  institution.  The  most  competent 
and  reliable  male  nurse  will  oftentimes  go  along  for  weeks  or  months,  attending 
conscientiously  to  his  duties,  taking  most  efficient  care  of  patients,  until  in  some 
unlucky  moment  he  finds  the  whisky  bottle  in  the  medicine  cabinet,  and  takes 
"just  a  drop  to  steady  his  nerves."  The  rest  of  the  story  is  easily  imagined.  It 
has  become  a  maxim  that  a  trained  male  nurse  would  not  be  a  nurse  if  he  were  fit 
for  any  other  occupation,  and  that  is  probably  true. 

So  that  time  and  events,  changed  conditions  everywhere,  have  practically 
eliminated  the  male  nurse,  except  for  certain  special  services  and  in  special  places. 
In  the  large  general  hospital  even  the  term  "male  nurse"  is  rarely  heard.  He  is  an 
"orderly"  now,  and  usually  has  all  the  weaknesses  of  the  old  male  nurse,  with  rarely 
few  of  his  good  points,  and  the  orderly,  as  we  have  come  to  know  him,  is  a  roving, 
restless  incompetent,  too  often  dishonest  in  a  petty  way,  and  rarely  efficient  enough 
to  give  the  nurses  very  much  intelligent  help. 

Of  course,  there  are  exceptions;  there  are  a  few  male  nurses  in  every  city  whose 
time  is  always  employed  at  remunerative  wages,  some  who  make  as  much  as  |30 
or  $40  per  week  and  are  always  busy;  and  there  are  a  few  orderlies  in  large  hospitals 
that  are  competent  men,  sober,  industrious  and  honest,  who  live  in  the  institution, 
who  save  their  money,  who  are  accommodating  in  their  work,  kind  to  patients: 
but  the  work  of  even  these  few  is  gradually  lowering  in  its  grade.  The  male  nurse 
used  to  catheterize,  give  enemas,  do  dressings,  and,  in  rare  instances,  do  minor 
surgery.  Nowadays  the  woman  nurse  gives  the  enema,  and  since  catheterization 
is  included  within  the  realm  of  aseptic  minor  surgery,  either  the  doctor  or  his  assist- 
ant performs  that  office  for  the  male,  while  the  woman  nurse  does  it  for  the  female 
patient.  So  that  the  orderly's  work  is  almost  reduced  to  a  janitor's  service.  He 
mops  the  dressing-rooms  and  sometimes  the  wards  and  halls.  He  may  occasionally 
give  an  enema  to  male  patients.  He  helps  lift  patients,  lie  puts  them  on  the  cart  for 
transportation  to  the  operating-room  ami  back  again.  He  is  called  to  control  delir- 
ious patients  occasionally,  by  reason  of  his  strength.  He  helps  with  the  service 
of  the  meals,  he  carries  the  stores  and  the  supplies  to  and  fro,  and  otherwise  make- 


336  OPERATION    OF   THE    HOSPITAL 

himself  generally  useful,  and  his  compensation  is  usually  $20  or  $40  per  month, 
with  room  and  board  in  the  institution. 

As  attendants  on  patients  in  insane  hospitals  and  public  eleemosynary  institu- 
tions, there  is  very  little  to  choose  between  men  and  the  ordinarily  employed 
women.  The  occupation  in  such  institutions  is  brutalizing,  and  as  the  public  is 
parsimonious  and  stingy  about  caring  for  its  wards,  and  as  charity  commissioners 
are  usually  negligent  where  they  are  not  ignorant,  and  as  superintendents  are  too 
often  political  proteges  of  politicians,  so,  "like  master  like  man,"  the  attendant 
male  and  female  are  calloused,  lazy,  often  dishonest,  and  rarely  possessed  of 
humanitarian  qualities. 

This  is  not  a  pleasant  section  to  write.  The  ideality  of  the  situation  as  com- 
pared with  the  reality  is  discomforting  and  discouraging.  There  is  no  reason 
why  there  should  not  be  competent  sober,  industrious  male  nurses.  The  price  of 
their  service  is  usually  regulated  by  the  value  of  that  service,  and  the  value  of  the 
male  nurse  has  receded,  and  has  reached  so  low  an  ebb,  along  with  his  deficiency 
and  his  frailties,  that  in  many  institutions  even  the  orderly  has  been  dispossessed, 
and  there  are  now  only  nurses  and  janitors,  and  this  condition  will  increase,  and 
male  attendants  in  institutions  will  become  rarer  as  the  trained  woman  nurse 
becomes  more  efficient  and  more  courageous  in  her  activities. 


RULES  FOR  TECHNICAL  DEPARTMENTS 

Rules  for  administrative  procedure  are  scattered  through  these  pages  with 
regard  to  their  specific  employment  and  in  the  various  proper  places  rather  than 
under  any  very  precise  order  as  rules.  The  following  rules  for  three  special  de- 
partments, it  is  thought,  are  so  important  that  they  had  best  be  assembled  at  this 
place. 

RULES  FOR  THE  SURGICAL  DEPARTMENT 

Following  are  a  few  general  rules  intended  to  apply  in  the  surgical  rooms 
of  the  average  general  hospital,  operating  under  the  ordinary  conditions  in  this 
country.  These  rules  can  be  amended  or  elaborated  or  cut  to  meet  special  condi- 
tions. 

General  Rules 

Visitors. — Physicians  only  shall  be  allowed  to  visit  the  operating  suite  while 
operations  are  in  progress,  and  under  no  circumstances  will  a  non-medical  person, 
whether  relative  or  friend  of  a  patient  or  otherwise,  be  allowed  to  be  present  at  a 
surgical  operation  without  the  specific  consent  of  the  superintendent  of  the  hospital 
in  each  case. 

Physicians  are  welcome  in  the  operating  department  under  the  following  condi- 
tions: 

They  must  don  visitor's  coat  or  slip  gown  before  going  into  the  arena  or  into  the 
private  operating-rooms. 

In  the  amphitheater  visitors  will  confine  themselves  to  the  seats  intended  for 
the  regular  audience,  and  must  not  enter  the  arena  except  on  specific  invitation 
of  the  operator. 

Visitors  must  respect  the  "private"  sign  on  operating-room  doors,  and  will 
enter  only  upon  the  specific  invitation  of  the  operator,  or  after  permission  from 
the  head  nurse  of  the  department. 

In  attendance  upon  operations  in  the  private  rooms  visitors  must  keep  outside 
the  zone  set  apart  for  nurses  and  assistants,  and  will  come  closer  only  upon  invita- 
tion, of  the  operator,  and  will  immediately  step  back  again  after  they  have  seen 
what  the  operator  wished  to  point  out. 

In  the  "clean"  rooms  when  a  visitor  has  been  invited  into  the  atmospheric 
field  of  operation,  he  must  be  clothed  in  head-cloth  and  mouth-cloth,  the  latter 
covering  nose,  mouth,  and  beard. 

Visitors  must  not  assist  in  any  way  in  the  operating-rooms,  unless  specifically 
invited  to  do  so  by  the  operator,  and  must  not  touch  trays,  tables,  or  any  o\  the 
paraphernalia  for  any  purpose. 

Visitors  will  enter  the  preparatory  or  anesthetizing  rooms  only  upon  invitation 
of  the  surgeon  in  charge  of  the  case. 

Schedules  of  operations  are  posted  in  the  surgeons'  dressing-room  and  in  the 
visitors'  locker  room;  the  schedule  book  upon  the  head  nurse's  desk  is  private 
property,  and  visitors,  whether  staff  members  or  not,  are  not  expected  to  peruse  it. 

•>2  W7 


338  OPERATION    OF   THE    HOSPITAL 

A  room  for  visitors  and  a  room  for  operators  is  provided;  those  who  are  not 
actually  at  work  are  requested  not  to  loiter  in  the  corridors  of  the  suite,  and  will, 
under  no  circumstances,  notice  patients  in  transit. 

Loud  talking  and  unnecessary  noise  are  prohibited. 

Visitors  to  the  city  who  desire  to  be  called  for  any  particular  operations  or  for 
any  surgeon's  schedule  must  leave  their  telephone  number  with  the  head  nurse,  and 
arrange  at  the  other  end  of  the  phone  for  the  taking  of  the  message  when  the 
number  is  called.  Out-of-town  men  may  be  notified  by  telegraph  or  long-distance 
telephone  twenty-four  hours  in  advance  when  possible,  at  their  expense. 

Operators.— Surgeons  who  participate  in  the  work  of  the  hospital  must  adhere 
to  the  institution  technic  in  so  far  as  asepsis  and  the  service  of  interns  and  nurses 
and  preparation  of  patient  are  concerned ;  it  is  only  in  this  way  that  an  adequate 
asepsis  and  assistance  can  be  maintained. 

Operators  are  expected  to  accept  the  dictum  of  the  head  nurse  in  the  schedul- 
ing of  operations. 

The  operating  schedule-book  will  be  in  the  custody  and  under  the  control  of 
the  head  nurse  of  the  department,  who  will  be  held  responsible  for  the  proper 
scheduling  and  conduct  of  operations. 

No  operation  will  be  set  down  for  a  time  that  would  naturally  make  it  lap  over 
on  another  operation  previously  scheduled,  and  the  head  nurse  must  be  the  final 
judge  as  to  this  time. 

Fifteen  minutes'  delay  will  be  considered  sufficient  to  meet  all  the  require- 
ments of  the  profession,  and  any  operator  who  is  more  than  fifteen  minutes  late 
for  an  operation  will  be  considered  to  have  forfeited  his  time,  and  must  then 
wait  until  the  regular  schedule  shall  have  been  completed.  His  patient  will  be 
returned  to  bed. 

Operators  are  expected  to  choose  their  instruments  for  any  operation  at  least 
half  an  hour  before  the  time  set  for  the  operation;  otherwise  the  institution's 
regular  tray  for  that  operation  will  be  picked  and  sterilized,  and  the  operator  will 
be  expected  to  get  along  with  those.  This  rule  is  made  necessary  to  avoid  un- 
necessary delays  in  sterilizing  additional  instruments. 

Operators  who  require  over-night  preparation  of  patients,  or  who  require  special 
instruments  or  apparatus  or  dressings,  must  give  orders  in  ample  time,  as  delays 
cannot  be  allowed  to  make  up  for  this  delinquency. 

.  Operators  are  expected  to  select  and  announce  the  anesthetic  they  wish  to 
employ  in  ample  time  for  preparation,  and  where  "continuous  gas"  is  to  be  used 
for  private  patients  the  operator  is  expected  to  inform  his  patient,  or  to  have  his 
intern  do  so,  that  there  is  a  special  charge  for  this  anesthetic. 

Operators  are  privileged  to  invite  any  physician  to  see  them  operate,  but  non- 
medical persons  will  not  be  allowed  in  the  operating-rooms  except  by  special  per- 
mission of  the  superintendent  of  the  hospital  in  each  case. 

The  private  assistant  of  any  operator  may  assist  him  in  any  private  case,  but 
the  institution  reserves  the  right  to  have  its  own  surgical  interns  scrubbed  up  and 
present  for  any  emergency. 

No  non-medical  person  will  be  allowed  to  assist  in  the  operating-rooms  in  any 
capacity  whatsoever,  excepting  the  regular  nurses  of  the  institution. 

Any  procedure  in  connection  with  a  surgical  operation  that  partakes  of  the 
nature  of  administrative  technic,  and  varies  in  any  way  from  the  regular  technic 
of  the  institution,  must  be  announced  to  the  head  nurse  before  the  operation  begins, 
and  must  have  her  approval;  any  appeal  on  this  point  must  be  made  to  the  super- 
intendent of  the  hospital. 


RULES  FOR  TECHNICAL  DEPARTMENTS  339 

The  Anesthetic. — No  anesthetic  will  be  commenced,  under  any  circumstances, 
until  the  operator  appears  in  the  operating  suite. 

No  outsider  will  be  permitted  to  administer  an  anesthetic  in  the  institution; 
the  hospital  maintains  a  corps  of  expert  operators  in  this  department,  who  are 
familiar  with  the  rules  of  the  institution  and  with  the  apparatus  available  for 
service. 

Members  of  the  house  medical  staff  are  not  permitted  to  administer  anesthetics 
until  they  have  been  passed  as  competent  by  the  regular  staff  men  on  service. 

In  exceptional  cases,  where  the  operator  has  reason  to  anticipate  difficulty 
with  the  anesthetic  because  of  the  patient's  condition,  one  of  the  regular  staff 
anesthetists  on  service  must  be  called  in,  after  due  notice  through  the  operator's 
intern,  and  in  such  case  the  operator  may  use  his  judgment  whether  the  patient 
should  pay  a  fee  to  the  special  anesthetist,  but  there  is  no  obligation  on  the  part 
of  the  patient  to  pay  such  fee  except  when  previous  arrangement  to  that  effect 
has  been  made  by  the  operating  surgeon  with  his  patient. 

The  regular  staff  anesthetists  may  be  called  upon  to  give  an  anesthetic  in  any 
case,  after  reasonable  notice,  and  they  are  forbidden  to  send  a  bill  to  any  patient 
for  such  service,  except  with  the  written  approval  of  the  operating  surgeon  as  an 
endorsement  on  the  bill,  and,  when  such  fee  is  permitted,  it  shall  not  be  more 
than  $10  in  any  case,  unless  specific  arrangement  to  that  effect  shall  have  been 
approved  by  the  superintendent  of  the  hospital. 

The  Patient. — No  patient,  whether  private  or  a  patient  in  a  free  ward,  shall 
be  taken  to  the  operating-room  until  the  following  conditions  have  been  complied 
with : 

(1)  Written  consent  for  the  operation,  signed  by  the  patient,  if  an  adult,  and 
in  mental  condition  to  give  such  consent,  on  the  regular  "permit  for  operation" 
form  of  the  institution;  if  the  patient  is  under  legal  age,  eighteen  years  in  females 
and  twenty-one  in  males,  or,  if  the  patient  is  unconscious  or  delirious  or  in  such 
mental  condition  as  to  be  unable  to  realize  the  gravity  of  the  operation,  the  permit 
must  be  signed  by  the  responsible  person  nearest  of  kin  available ;  if  there  is  no  such 
person  present  or  available,  the  facts  must  be  stated  to  the  superintendent  of  the 
hospital,  who  may  use  his  discretion  in  issuing  a  special  permit,  on  the  face  of  which 
all  the  facts  must  be  stated.  This  permit  must  be  taken  to  the  operating-room  as  a 
part  of  the  regular  record  of  the  case.  This  permit  must  be  had  whether  the  anes- 
thetic is  to  be  general  or  local. 

(2)  No  patient  shall  be  taken  to  the  operating-room  without  a  complete  urine 
examination,  and  the  laboratory  report  must  accompny  the  patient  as  a  part  of 
the  record.  In  the  event  that  a  specimen  of  urine  cannot  be  obtained  for  analysis, 
the  superintendent  of  the  hospital  must  be  notified  of  the  facts,  and  he  may,  in  his 
discretion,  issue  a  waiver  permitting  the  operation,  but  the  reasons  therefor  must 
be  stated  in  the  superintendent's  handwriting  on  the  permanent  record  of  the  case. 

(3)  No  patient  shall  be  taken  to  the  operating-rooms  until  arrangements  are 
completed,  assuring* the  commencement  of  the  operation  within  fifteen  minutes 
after  the  patient's  arrival  there.  If,  for  any  reason,  a  longer  wait  is  necessary 
the  patient  must  be  taken  back  to  bed.  This  rule  is  to  guarantee  prompt  attention 
to  patients,  so  that  they  may  not  be  kept  under  hurtful  suspense  unduly. 

At  the  end  of  an  operation  no  patient  shall  be  taken  back  to  bed  without 
the  attendance  of  a  responsible  medical  man.  preferably  an  intern  of  the  institution. 

No  patient  shall  be  left  alone,  for  even  the  shortest  interval,  in  the  operating- 
room  suite.    A  physician  or  nurse  must  always  be  present  in  the  room. 

Immediately  following  the  operation,  it   -hall  lie  the  duty  of  the  first  assistant 


340  OPERATION    OF   THE    HOSPITAL 

to  the  operator  to  see  that  the  patient  is  removed  from  the  table  to  the  stretcher  and 
properly  prepared  for  the  journey  back  to  bed.  He  must  likewise  be  convinced  that 
the  patient  is  in  good  condition  before  transfer  to  the  stretcher  is  attempted. 

THE  CHILDREN'S  DEPARTMENT 

General  Rules 

Visitors. — Visiting  time  in  the  children's  department  shall  be  as  follows: 

Large  (free)  wards,  2  to  4  p.  m.,  Wednesday  and  Sunday. 

Small  (private)  wards,  1  to  8  p.  m.  daily,  in  the  discretion  of  attending  physicians. 

Private  rooms,  without  other  limitations  than  the  orders  of  attending  physician. 

In  Isolation. — No  visitors  at  any  time,  upon  any  pretext  whatsoever  (excepting 
in  cases  of  impending  death,  and  then  under  detailed  supervision  of  the  superin- 
tendent of  the  hospital). 

Only  the  parents  or  guardian  will  be  permitted  to  visit  patients,  excepting  on 
the  specific  order  of  the  superintendent  of  the  hospital  in  each  case. 

Children  will  not  be  permitted  to  visit  in  the  children's  department. 

Visitors  of  whatever  class,  whether  parents,  visiting  physicians,  or  casual 
guests  of  the  hospital,  shall  be  clothed  in  the  regulation  visitor's  gown  of  the  insti- 
tution before  entering  the  rooms  where  there  are  sick  children. 

Visitors,  whether  parents  or  others,  will  not  be  allowed  to  handle  the  sick 
children,  or  to  wait  upon  them,  or  to  give  them  anything  to  eat  or  play  with  without 
the  express  permission  of  the  head  nurse  in  charge  in  each  particular  instance. 

Note. — These  rules  relative  to  visitors  do  not  apply  to  members  of  the  young 
ladies'  society  detailed  to  entertain  the  children,  and  whose  conduct  is  prescribed  in 
special  rules. 

Admission  of  Patients. — No  patient  shall  be  admitted  by  the  physician  detailed 
in  the  admission  rooms  until  a  throat  smear  has  been  made  and  found  negative 
in  all  cases,  and  a  vaginal  smear  has  been  made  and  found  negative  in  all  female 
children.  When  either  of  these  findings  shall  have  been  found  positive,  the  super- 
intendent of  the  hospital  shall  be  immediately  notified  for  discretionary  action  in 
the  case. 

Whether  the  smears  prove  positive  or  negative,  it  shall  be  the  duty  of  the 
admitting  physician  to  take  cultures  from  throat  and  vagina,  and  send  them  to  the 
incubator  in  the  general  laboratory  of  the  institution  for  final  treatment  and 
report. 

After  admission,  cultures  from  throat  and  vagina  shall  be  taken  each  day  for 
three  days  by  the  junior  house  physician,  carefully  examined,  and  the  findings 
added  as  a  part  of  the  permanent  record,  and  twice  a  week  thereafter. 

As  soon  as  a  patient  has  been  admitted  by  the  physician  it  shall  be  the  duty  of 
the  admission  nurse  to  remove  all  clothing  in  the  presence  of  one  of  the  house  phy- 
sicians in  that  service,  whose  duty  it  shall  be  to  examine  the  body  of  the  patient 
for  bruises,  eruptions,  marks  of  all  kinds,  malformations  and  irregularities,  and  to 
make  note  of  them  on  the  history  sheet  as  part  of  the  routine  physical  examination. 
The  nurse  shall  immediately  thereafter,  unless  forbidden  to  do  so  on  account  of  the 
critical  condition  of  the  patient,  give  it  the  regular  bath  prescribed,  weigh  the  patient 
naked,  clothe  it  in  the  hospital  bed  clothing,  and  put  it  to  bed  in  the  prescribed 
location. 

After  one  hour  the  nurse  shall  take  the  temperature,  pulse,  and  respiration, 
and  record  them  as  a  part  of  the  admission  entry  in  the  nursing  chart. 


RULES   FOE   TECHNICAL   DEPARTMENTS  341 

Before  the  parents  of  the  child  shall  have  left  the  hospital  it  shall  be  the  duty 

of  the  junior  house  physician  to  interrogate  them  on  the  history  of  the  ease,  as 
prescribed  under  the  rules  for  history  taking,  and  to  record  their  story  in  detail 
on  the  record.  As  soon  as  possible,  and,  in  any  event,  within  twelve  hours  after 
the  admission  of  the  patient,  the  junior  house  physician  shall  make  and  record  a 
complete  urine  examination,  and  shall,  in  addition,  examine  the  blood  or  such  other 
excreta — fluids,  tissue — as  in  his  judgment  are  likely  to  prove  of  value  in  the 
physical  examination  to  he  made  later  by  the  attending  physician. 

As  soon  as  the  routine  admission  service  has  been  performed  it  shall  be  the  duty 
of  the  junior  house  physician  to  notify  his  senior  of  the  admission  of  the  patient, 
and  it  shall  be  the  duty  of  the  senior  to  see  the  patient  at  once.  If.it  is  a  private 
case,  he  shall  at  once  call  the  attending  physician  by  'phone,  notify  him  of  the  ad- 
mission of  the  patient  and  the  present  condition,  and  ask  for  orders.  If  it  is  a  ser- 
vice (free)  case,  he  shall  at  once  make  a  complete  physical  examination,  record  his 
finding  on  the  permanent  record,  according  to  the  rule  for  making  physical  examina- 
tions, and,  in  his  discretion,  shall  give  the  necessary  orders,  or  call  up  the  service 
attending  physician,  relate  the  facts,  and  ask  for  advice. 

Every  patient,  upon  admission,  shall  be  assigned  to  a  bed  in  one  of  the  observa- 
tion rooms  of  the  department,  and  shall  not,  under  any  conditions  whatever,  be 
removed  to  a  ward  in  which  there  are  other  children  until  so  ordered  by  the  attend- 
ing physician  in  the  service. 

Care  of  Children. — Immediately  upon  admission,  it  shall  be  the  duty  of  the  ad- 
mitting nurse  to  examine  the  patient  carefully  for  head  and  body  vermin.  The 
general  bath  will  be  adjudged  sufficient  treatment  for  body  lice;  when  found  on  the 
head,  she  will  apply  the  institution's  technic  prescribed,  and  the  treatment  will  be 
continued  until  the  patient's  head  is  free  from  them.  But  under  no  circumstances 
will  it  be  permitted  to  cut  a  female  patient's  hair,  except  with  the  express  consent 
of  the  parents  or  an  order  from  the  superintendent  of  the  hospital. 

A  full  bath,  either  tub  or  sponge,  must  be  given  every  patient  daily  except  on 
counter  order  of  the  physician. 

Children's  hair  must  be  kept  combed,  and,  in  the  case  of  females  with  long  hair, 
it  must  be  braided  and  neatly  tied  with  ribbon  or  tape. 

Finger-  and  toe-nails  must  be  kept  trimmed  and  neatly  manicured  at  all  times. 

Tooth-brushes  are  provided  by  the  institution  for  older  children,  who  must  be 
taught  their  proper  use  whenever  their  health  permits,  and  the  mouths  and  teeth 
of  all  children  must  be  kept  clean. 

In  the  case  of  infants  the  nurse  is  forbidden  to  clean  the  mouths  with  her  finger, 
but  must  use  a  soft  mop  made  of  wooden  handle  and  absorbent  cotton  swab. 
The  handle  must  be  notched,  so  that  the  swab  when  tied  on  will  not  slip  off.  In  the 
absence  of  special  orders  by  the  physician,  a  saturated  boric  acid  solution  may  be 
used  for  mouth-wash. 

Each  child  must  have  its  own  comb  and  brush  while  in  the  hospital,  and  the  comb 
and  brush  that  have  served  one  child  shall  not  be  used  again  until  they  have  been 
completely  sterilized  by  soaking  in  a  solution  of  1  :  4000  bichlorid  for  at  least  six 
hours  and  then  rinsed  in  clean  sol'1  water.     Brushes  and  combs  must  not  be  boiled. 

The  genitals  and  buttocks  of  each  infant  must  be  given  careful  attention  l>\ 
washing  in  warmed  water  after  each  bowel  movement  and  must  be  kepi  well  pow- 
dered with  talcum.  The  id  a  ns  and  foreskin  of  male  children  must  be  watched  care- 
fully and  kept  clean,  and  every  female  infant  shall  have  a  vulval  pail  in  COnstanl 
use,  and  this  must  be  changed  whenever  we1  or  soiled.  Any  discharge  in  cither  --ex 
must  be  communicated  to  the  physician  in  charge. 


342  OPERATION    OF   THE    HOSPITAL 

Each  child  large  enough  to  use  bed-pan  and  urinal  must  have  separate  utensils 
of  both  sorts,  and  these  must  not  be  used  for  any  other  child.  After  each  use  they 
must  be  scalded  and  passed  through  the  prescribed  disinfecting  utensil  sterilizer. 

Each  child,  large  and  small,  shall  have  separate  wash-basin,  wash-cloth,  cup, 
spoons,  and  dishes,  and  these  shall  be  identified  by  number  of  bed. 

Each  child  shall  have  its  own  thermometer,  rectal  for  infants,  and  both  rectal 
and  mouth  for  older  children,  kept  in  proper  receptacle  at  the  bedside,  and  after 
each  use  it  shall  be  washed  and  carbolized  or  disinfected  in  the  institution's  routine 
way. 

When  a  patient  is  discharged  all  utensils  and  thermometers  shall  be  passed 
through  the  special  sterilizing  process  for  the  required  time  before  being  used 
again. 

Infants'  diapers  must  be  kept,  when  containing  bowel  movement,  in  the  special 
receptacle  provided  for  them  in  the  slop-sink  room  until  the  next  visit  of  the  attend- 
ing physician;  they  must  then  be  cleaned  of  feces,  and  placed  to  soak  in  5  per 
cent,  carbolic  solution  for  twelve  hours,  then  rinsed,  and  sent  to  the  laundry  for 
washing. 

All  linens  in  the  children's  department,  bed  clothing  of  patients,  sheets,  slips, 
and  pads,  must  be  soaked  in  5  per  cent,  carbolic  solution  for  twelve  hours  before 
being  sent  to  the  hospital  laundry. 

Nursing  and  bottle  infants  must  invariably  be  fed  by  prescription  of  the  physi- 
cian as  to  time,  amount,  temperature,  and  kind  of  food,  and  at  least  once  daily 
each  nursling  must  be  weighed  naked  before  and  after  feeding  to  test  the  integrity 
of  the  method.  No  nursling  must  be  left  alone  while  feeding  from  the  bottle;  the 
nurse  must  remain  and  hold  the  bottle  during  the  whole  process,  or,  when  the  auto- 
matic bottle-holder  is  used,  a  nurse  may  watch  and  aid  all  the  children  in  the  ward 
while  nursing. 

Infants  nursing  wet  nurse  must  be  especially  watched  for  weight,  to  see  that  the 
foster  mother  gives  her  charge  an  honest  feeding. 

Infants'  mouths  must  not  be  washed  after  nursing  except  on  the  order  of  the 
physician. 

Rules  for  Handling  Wet  Nurses. — In  the  modern  hospital  for  children  there  will 
come  many  babies  suffering  from  gastro-intestinal  disorders,  who,  the  doctors  insist, 
cannot  live  unless  they  are  fed  mothers'  milk,  and  for  these  cases  many  institutions 
are  now  finding  it  necessary  to  employ  wet  nurses. 

Almost  invariably  these  women  are  from  the  lowest  classes  of  society;  they  are 
usually  ignorant,  and  their  standards  are  often  very  little  higher  than  those  of  the 
lowest  animals.  Most  of  them  are  unmarried,  and  some  of  them  even  make  a 
business  of  wet  nursing,  and  to  that  end  become  pregnant  and  give  birth  to  a  new 
child  as  often  as  occasion  seems  to  require.  Of  course,  there  is  an  occasional  wet 
nurse  who,  from  misfortune,  has  been  obliged  to  seek  employment  of  this  charac- 
ter to  tide  over  the  time  until  her  baby,  with  whom  she  has  been  left  dependent, 
arrives  at  an  age  that  will  permit  her  to  make  a  living  in  some  other  avenue;  but  the 
great  mass  of  wet  nurses  must  be  handled  within  rigid  rules,  without  much  reference 
to  sentiment  of  any  sort,  if  they  are  to  be  of  service  to  the  institution  in  the  feeding 
of  sick  babies.  As  a  rule,  the  children  of  these  wet  nurses  are  healthy,  and  a  con- 
siderable part  of  their  food  can  be  made  up  of  formula  milks  without  any  harm  to 
them,  and,  in  any  event,  it  is  always  necessary  to  know  exactly  what  each  woman 
can  supply  for  the  use  of  other  children  and  her  own,  and  to  this  end  there  are  some 
very  definite  rules  that  can  be  laid  down,  and  which  must  be  insisted  upon  if  the 
nurse's  service  in  the  institution  is  to  be  of  any  value. 


RULES    FOR   TECHNICAL   DEPARTMENTS  343 

First:  The  wet  nurse  is  never  permitted  to  have  her  child  with  her  except  at 
feeding  time,  and  then  for  not  more  than  fifteen  or  twenty  minutes  after  the  breasl 
has  been  emptied  as  well  as  may  be  for  the  feedings  of  the  children  whom  she  is 
nourishing.  Sick  babies  are  not  permitted  to  nurse  from  the  wet  nurses'  breasts; 
the  milk  must  be  drawn  by  the  wet  nurse  herself  into  a  graduated  bottle,  a  sufficient 
quantity  in  each  bottle  for  the  nursing  of  one  baby,  and  the  milk  so  drawn  must  be 
fed  to  the  sick  baby  while  it  is  yet  warm;  milk  must  be  drawn  in  the  presence  of 
a  nurse. 

Second:  Wet  nurses  must  not  be  allowed  to  go  to  a  general  table  for  their  meals, 
but  must  have  their  meals  brought  to  them  where  they  may  partake  of  their  food 
under  the  eye  of  a  nurse  wdio  understands  what  their  diet  is  to  be.  Wet  nurses 
have  precarious  appetites,  as  a  rule,  and  they  are  more  likely  than  not  to  have  a 
craving  for  something  that  will  either  diminish  the  amount  of  their  milk  or  impart 
some  condition  that  will  make  it  disagree  with  the  sick  babies.  Wet  nurses  should 
be  fed  on  the  plainest  food,  and  the  more  protein  in  character  the  better  it  will  be ; 
rare  meats,  legume  vegetables,  whole  wheat  and  cornbreads,  milk,  eggs,  butter,  and 
a  sufficient  amount  of  bulk  foods  to  fill  the  stomach  and  thus  make  them  satisfied ; 
potatoes  and  bread  are  the  chief  of  these  latter. 

Third:  Wet  nurses  should  be  kept  rigidly  within  regular  hours  in  the  insti- 
tution. They  should  not  be  permitted  to  go  out  after  night,  because  they  will  do 
indiscreet  things,  eat  foods  calculated  to  interfere  with  their  efficiency  as  wet  nurses, 
drink  alcoholic  stimulants,  and  so  upset  themselves  generally  that  the  milk  supply 
will  be  diminished.  On  the  other  hand,  the  wet  nurses  should  be  made  comfortable, 
and  should  be  given  a  sufficient  amount  of  work  in  the  institution  to  keep  them 
busy.  They  are  disposed  to  resent  restraint,  and,  unless  their  time  is  fully  occupied, 
they  will  be  sure  to  fret,  and  thus  diminish  their  milk  supply. 

Fourth:  The  wet  nurses  should  be  obliged  to  observe  the  laws  of  health  and 
cleanliness ;  they  should  be  obliged  to  bathe  regularly,  and  it  should  be  the  duty  of 
the  head  nurse  of  the  department  to  see  that  their  bowels  are  kept  in  proper  condi- 
tion and  that  their  genitals  are  clean  and  healthy. 

Fifth :  Wet  nurses  should  never  be  employed  until  the  Wassermann  test  has  been 
made,  and  until  a  competent  physician  has  given  them  a  thorough  examination,  to 
determine  the  presence  or  absence  of  specific  disease.  They  should  never  be  per- 
mitted to  go  on  duty  with  running  ears,  sore  eyes,  sore  throat,  bad  teeth,  or  any 
discharge  from  a  mucous  membrane  or  any  skin  eruption. 

Sixth:  The  wet  nurse  should  be  given  a  certain  number  of  babies  to  feed,  and, 
as  long  as  her  milk  agrees  with '.them,  should  be  kept  to  the  same  babies  without  any 
admixture  of  the  milk  of  any  other  nurse.  A  change  of  wet  nurses  has  been  known 
to  destroy  whatever  gain  had  been  made  by  a  sick  baby,  and  to  cost  the  life  of  the 
child. 

Seventh:  The  wet  nurse  that  cannot  produce  at  least  32  ounces  of  milk  per 
twenty-four  hours,  in  addition  to  what  is  required  for  her  own  baby,  is  not  worth 
keeping,  and  there  are  many  of  them  who  produce  twice  that  much  or  even  three 
times. 

RULES  GOVERNING  MATERNITY  DEPARTMENT 

These  rules  are  created  by  the  obstetrical  staff  of  the  Michael  Reese  Hospital, 
and  are  approved  by  the  board  of  directors.  They  will,  therefore,  govern  the  con- 
duct of  all  who  have  to  do  with  the  department,  whether  it  he  start'  members,  visit- 
ing obstetricians  in  charge  of  patients,  interns,  nurses,  patients,  or  the  public. 


344  OPERATION    OF   THE    HOSPITAL 


General   Rules 


No  one  will  be  permitted  to  perform  any  service  in  the  maternity  depart- 
ment of  any  character  whatsoever  who  has  bad  or  decaying  teeth,  any  discharge 
from  any  mucous  membrane,  or  any  open  sore  upon  any  part  of  the  body,  or  who  has 
been  within  the  sphere  of  any  communicable  disease  within  the  past  twenty-four 
hours. 

No  babe  whose  mother  is  a  patient  in  the  maternity  department  shall  be  taken 
out  of  the  bounds  of  the  department  for  any  reason  whatsoever  without  the  consent 
of  the  attending  physician  in  the  case  and  the  approval  of  the  superintendent  of 
the  hospital;  and  no  baby  that  has  been  removed  under  such  consent  can  be  returned 
to  the  department  without  the  specific  consent  of  the  superintendent  of  the  hos- 
pital; provided,  however,  that  this  rule  shall  not  apply  in  cases  where  the  mother 
occupies  a  room  in  another  part  of  the  hospital,  in  which  case  the  babe  must  be 
carried,  thoroughly  wrapped  up,  directly  to  and  from  the  nursery,  without  exposure 
at  any  point  en  route,  and  such  child  shall  not  be  allowed  in  the  room  with  its  mother 
during  the  presence  there  of  any  other  child  under  fifteen  years  of  age. 

Visitors. — The  regular  visiting  hours  are  as  follows:  Large  wards,  Sunday  and 
Wednesday,  2  to  4  p.  at.  Small  wards,  daily  from  1  to  8  p.  at.  Private  rooms, 
daily  from  1  to  8  p.  at. 

Visitors  in  the  large  wards  will  be  absolutely  restricted  to  husband  and  parents 
of  the  patient. 

In  other  parts  of  the  department  indiscriminate  visiting  is  to  be  discouraged, 
and  should  be  confined  to  the  immediate  family  of  the  patient. 

Children  under  fifteen  years  of  age  will  not  be  permitted  to  visit  in  the  depart- 
ment under  any  circumstances  whatever. 

No  physician  will  be  permitted  to  visit  the  patient  of  another  physician  in  the 
department,  except  on  specific  invitation  of  the  attending  physician;  provided, 
however,  that  this  rule  does  not  release  the  staff  director  of  the  department  from 
observing  the  necessary  supervision  over  all  patients  to  maintain  cleanliness  and 
asepsis. 

Visitors  in  the  department,  excepting  those  who  call  exclusively  upon  patients 
in  private  rooms,  must  wear  the  hospital  sterilized  gowns  provided  for  the  purpose; 
gowns  from  other  parts  of  the  hospital  will  not  be  allowed. 

Visitors  must  not  sleep  in  the  maternity  department  under  any  circumstance. 
Relatives  of  critically  ill  patients  may  be  provided  for  in  other  parts  of  the  hospital. 

Interns  and  nurses  on  duty  in  other  parts  of  the  hospital  will  not  be  permitted 
to  visit  the  maternity  department  except  by  special  permission  of  the  head  nurse 
and  under  rigid  precautions. 

Admission  of  Patients. — No  patient  shall  be  allowed  to  enter  the  precincts  of 
the  department,  except  in  extreme  urgency,  until  the  house  physician  on  duty 
in  the  department  shall  have  examined  her  (not  vaginally)  to  make  sure  she  is  free 
from  infection.  Immediately  upon  the  entry  of  a  patient  in  the  hospital  the  proper 
house  physician  must  be  notified. 

When  a  patient  is  admitted,  clothes  and  all  personal  belongings  must  be  labeled 
and  registered,  valuables  given  to  the  head  nurse  in  charge  of  service,  who  shall 
take  them  to  the  office  and  receive  receipt  for  same;  in  the  event  of  neglect  or  loss 
to  account  for  same,  the  head  nurse  will  be  held  financially  responsible.  Clothing 
must  be  listed  and  sent  to  the  storekeeper,  who  will  receipt  for  same  after  checking, 
and  who  will  be  held  responsible  for  all  pieces  receipted  for.  The  head  nurse  will 
be  held  responsible  for  lost  articles  not  listed. 


RULES    FOR   TECHNICAL    DEPARTMENTS  345 

Discharge  of  Patients. — No  private  patient  shall  be  sent  home  or  allowed  to 
leave  until  explicitly  discharged  by  the  attending  physician. 

No  bleeding  patient,  and  no  patient  presenting  any  abnormalitity  of  any  kind, 
shall  be  discharged  except  upon  the  explicit  order  of  the  physician  in  charge. 

Patients  must  be  discharged  and  prepared  to  leave  the  hospital  so  that  they  shall 
be  at  home  before  dark  in  the  evening,  that  is,  7  o'clock  in  the  summer  and  4  o'clock 
in  the  winter. 

No  patient  shall  be  allowed  to  leave  the  hospital  unless  patient  and  baby  are 
comfortably  clothed,  considering  the  season. 

No  patient  shall  be  allowed  to  leave  the  hospital  without  an  escort  competent 
to  see  her  and  her  baby  safely  home  under  every  circumstance. 

No  patient  shall  be  allowed  to  leave  the  hospital  without  a  definite  destination, 
and  without  abundant  assurance  that  she  and  her  baby  will  be  properly  cared  for. 

Consent  for  Operation. — No  instrumental  delivery,  or  delivery  by  surgical  inter- 
ference, will  be  permitted  under  any  circumstances  without  competent  consent  in 
writing  of  the  patient;  if  the  patient  be  incapable  of  giving  intelligent  written  con- 
sent, same  must  be  obtained  from  husband  or  other  responsible  relative,  and,  in  the 
absence  of  any  of  these,  the  attending  physician  must  avail  himself  of  the  counsel  of 
the  nearest  available  physician  in  active  practice,  both  of  whom  shall  sign  a  state- 
ment of  the  facts  in  the  case.  If  there  is  no  such  available  consultant,  the 
facts  must  be  communicated  to  the  superintendent  of  the  hospital,  who  will  sign  a 
special  permit,  setting  forth  the  facts  in  the  case  for  any  legal  review  that  may 
follow. 

Isolation  of  Mother  and  Baby. — Whenever  any  infection  shall  occur  in  mother 
or  child  the  superintendent  of  the  hospital  must  be  notified,  and  patient  and  babe 
shall  be  at  once  completely  isolated  to  the  satisfaction  of  the  medical  staff.  If 
this  cannot  be  done  satisfactorily,  other  accommodation  must  be  found,  and  patient 
and  babe  removed  at  once.  The  medical  staff  of  the  department  shall  be  the  judge 
of  what  is  an  isolatable  infection  and  what  is  satisfactory  isolation. 

No  private  patient  shall  be  transferred  from  the  maternity  department  to  make 
room  for  another  patient  without  the  consent  of  the  attending  physician,  and  the 
manner  and  place  of  removal  shall  be  satisfactory  to  the  patient  and  her  attending 
physician. 

Circumcisions. — The  operation  of  circumcision  shall  be  performed  in  the  matern- 
ity department  precisely  in  the  manner  and  under  the  asceptic  technic  of  the  sur- 
gical department  of  the  hospital. 

All  operators  shall  scrub  their  hands  with  brush  and  marble-dust  soap  for  twenty 
minutes,  cleaning  finger-nails  thoroughly.  They  shall  wear  the  regulation  operating- 
room  gown  and  rubber  gloves.  Their  instruments,  thread,  and  dressings  must  be 
sterilized  by  the  nurses  in  the  department  in  the  usual  way.  Bleeding  vessels 
must  be  carefully  tied,  and  the  parts  must  be  stitched  and  the  operation  performed 
in  every  way  according  to  accepted  aseptic  surgical  procedure. 

If  the  operation  is  performed  as  part  of  a  religious  rite,  the  operator  must  agree 
in  writing  beforehand,  and  the  agreement  made  a  part  of  the  record  of  the  patient . 
that  he  will  perform  the  operation  strictly  in  accordance  with  the  above  rule. 

There  may  be  three  persons  present  at  any  circumcision  beside  the  hospital 
assistants,  of  whom  the  operator  shall  be  one;  the  others  may  be  selected  by  the 
family  of  the  child. 

No  circumcision  shall  be  performed  on  any  child  who  is  not  perfectly  healthy. 

No  person  shall  perform  the  operation  of  circumcision  without  the  written  con- 
sent of  mother  or  father,  and  said  written  permit  shall  state  who  is  to  perform  the 


346  OPERATION    OF   THE    HOSPITAL 

operation,  and  the  written  permit  must  be  made  a  part  of  the  permanent  record  of 
the  case. 

No  person  not  connected  with  the  hospital  shall  be  allowed  to  perform  the  opera- 
tion of  circumcision  until  he  shall  have  signed  an  agreement  to  abide  by  the  rules 
of  the  hospital  as  to  asepsis  and  methods  of  cleanliness  and  technic. 

No  intern  shall  perform  the  operation  of  circumcision  without  the  express  con- 
sent of  the  staff  obstetrician  on  duty  in  the  department  at  the  time,  and  never 
without  the  written  consent  of  one  parent. 

Authority  in  the  Maternity  Department. — The  obstetric  staff  of  the  Michael 
Reese  Hospital  will  be  responsible  for  the  medical  and  scientific  conduct  of  the 
department,  and  will  have  full  authority  to  that  end. 

The  physician  in  charge  of  each  case  will  give  whatever  orders  he  may  desire 
relating  to  his  own  patient,  and  they  will  be  carried  out  by  interns  and  nurses,  unless 
they  are  in  violation  of  these  rules,  in  which  case  the  person  to  whom  the  order  is 
given  will  notify  him  of  the  rule,  and,  if  the  physician  persists,  the  head  nurse 
of  the  department  will  be  notified,  and,  if  the  physician  still  persists,  the  superin- 
tendent of  the  hospital  will  be  at  once  notified  of  the  facts. 

Interns  on  duty  in  the  department  are  supposed  to  know  the  wishes  of  visiting 
physicians  in  relation  to  their  patients,  and  their  orders  will  be  carried  out,  subject 
only  to  countermand  by  the  head  nurse  of  the  department  until  the  attending  phy- 
sician can  be  reached  for  a  final .  decision. 

The  Head  Nurse. — The  head  nurse  of  the  department  shall  be  in  direct  charge 
of  all  the  work.  She  shall  be  held  responsible  for  the  technic,  excepting  that  of 
attending  physicians  and  interns,  and  her  orders  in  every  case,  and  under  all  cir- 
cumstances, shall  prevail,  subject  to  approval  (1)  by  the  medical  staff  in  relation  to 
medical  and  scientific  matters,  (2)  the  attending  physician  in  regard  to  any  indi- 
vidual case,  and  (3)  the  superintendent  of  the  training-school  in  all  matters  in  rela- 
tion to  the  nursing  of  patients  and  the  nursing  technic  of  the  department. 

The  head  nurse  shall  be  in  charge  of  all  supplies  of  every  description,  and  shall 
be  held  responsible  for  their  economic  and  proper  distribution  and  use. 

The  head  nurse  shall  be  responsible  for  the  cleanliness  and  asepsis  of  the  depart- 
ment and  all  its  belongings,  and,  to  that  end,  will  be  in  authority  over  all  the  order- 
lies, floormen,  and  maids,  as  well  as  nurses  who  are  detailed  for  duty  there. 

The  head  nurse  must  conduct  drills  of  technic  and  in  the  conduct  of  typical 
cases  at  intervals  when  the  department  is  not  busy. 

In  the  event  of  a  difference  of  opinion  between  the  head  nurse  and  a  visiting 
physician  or  an  intern,  she  shall  at  once  notify  the  superintendent  of  the  training- 
school,  or,  in  her  absence,  the  superintendent  of  the  hospital,  for  a  decision  of  the 
question. 

The  head  nurse  shall  report  all  abnormalities  of  patients  and  unusual  conditions 
to  the  house  physician  at  once,  and  to  the  attending  physician  on  his  next  visit. 

In  addition  to  her  other  duties,  the  head  nurse  shall  keep  a  book  in  which  she 
shall  record  all  mooted  questions  that  may  arise  appertaining  to  the  conduct  of  the 
department,  to  the  end  that  the  rules  may  be  amended  from  time  to  time. 

Rules  for  Attending  Physicians. — Physicians  working  in  the  maternity  depart- 
ment, whether  members  of  the  medical  staff  of  the  Michael  Reese  Hospital  or  other- 
wise, must  conduct  their  cases,  in  so  far  as  operative  technic  is  concerned,  in  strict 
conformity  with  these  rules. 

Attending  physicians  are  expected  to  visit  their  patients  daily. 

For  the  protection  of  the  department,  and  to  safeguard  its  asepsis  and  clean- 
liness, the  staff  member  on  service  is  directed  to  inspect  all  parts  of  the  premises  at 


RULES    FOR   TECHNICAL    DEPARTMENTS  347 

frequent  intervals,  and  to  maintain  sufficient  watchfulness  over  the  work  of  attend- 
ing physicians  and  over  their  patients  to  guarantee  this  result  in  the  conduct  of  the 
department. 

The  staff  physicians  are  expected  to  co-operate  with  the  hospital  in  the  taking 
and  keeping  of  the  prescribed  records,  and  to  frequently  inspect  such  records  to  see 
that  they  are  being  adequately  kept. 

Attending  physicians  are  urged  to  call  consultations  freely  in  difficult  cases,  not 
only  to  protect  their  own  interests  in  a  medicolegal  sense,  but  to  divide  responsi- 
bility. Service  members  of  the  staff  are  urged  to  call  freely  upon  the  advice  and 
counsel  of  their  confreres,  not  only  for  the  above  reasons,  but  in  order  to  share 
their  experience  in  regard  to  interesting  cases. 

Physicians  are  urged  to  read  carefully  all  rules  of  the  department,  to  the  end 
that  they  may  not  be  embarrassed  by  the  refusal  of  the  interns  and  nurses  to  obey 
their  orders. 

Rules  for  Interns. — The  division  of  labor  between  seniors  and  juniors  will  be 
made  as  in  other  parts  of  the  hospital,  excepting  that  no  junior  shall  conduct  a  case 
of  labor  unaided  until  pronounced  competent  by  his  senior. 

In  case  of  abnormality,  the  junior  must  immediately  notify  his  senior  and  take 
orders  in  relation  thereto.  The  senior  intern  must  immediately  report  any  ab- 
normality to  the  obstetrician  on  service,  if  it  is  a  service  case,  and  to  the  attending 
physician  in  a  private  case.  If  the  regular  attendant  cannot  be  located,  another 
staff  member  must  be  called,  and,  if  none  can  be  found,  the  superintendent  of  the 
hospital  must  be  notified  of  the  facts.  In  a  private  case,  if  the  attending  physician 
cannot  be  located  in  an  emergency,  the  superintendent  of  the  hospital  must  be 
notified.    • 

The  intern  on  duty,  and  who  has  begun  a  case  of  labor,  must  remain  within 
easy  call  of  the  nurses  until  the  case  is  over,  or  until  he  has  expressly  resigned  the 
case  to  another  intern  and  has  notified  the  nurses  to  that  effect.  In  the  event  that 
an  intern  does  so  resign  a  case  in  favor  of  another,  he  must  write  the  conditions  of 
the  patient  as  they  exist  at  the  time  he  leaves  the  case,  and  said  written  directions 
must  be  made  a  part  of  the  permanent  record  of  the  case. 

An  intern  who  has  begun  as  a  participant  in  an  abnormal  case  will  under  no 
conditions  whatsoever  leave  until  the  case  is  concluded. 

Interns  are  not  allowed  to  reprimand  nurses.  Any  incompetence  or  neglect 
of  duty  must  be  reported  to  the  head  nurse. 

Interns  on  duty  in  the  maternity  department  are  forbidden  to  visit  the  morgue, 
to  be  present  at  any  autopsy,  whether  human  or  animal,  and  are  expressly  for- 
bidden to  participate  in  any  pus  operation  or  dressing  except  under  conditions  that 
may  be  prescribed  by  the  medical  staff  of  the  department. 

Books  used  by  interns  during  student  days,  such  as  anatomies,  books  on  path- 
ology, and  physiology,  shall  not  be  brought  into  the  maternity  department. 

The  intern  on  duty  must  make  rounds  twice  daily  in  all  cases,  and  as  much 
oftener  as  may  be  necessary. 

Rules  for  Maternity  Nurses.— All  pupil  nurses  on  duty  in  the  maternity 
department  will  be  under  the  direct  jurisdiction  of  the  head  nurse  of  the 
department. 

In  the  absence  of  the  head  nurse  a  senior  pupil  nurse  must  lie  left  in  charge, 
whose  orders  will  be  as  implicitly  obeyed  by  other  nurses  as  though  given  by  the 
head  nurse  direct,  and  whose  authority  in  the  department  will  follow  that  of  the 
head  nurse.  Whenever  a  pupil  nurse  in  charge  of  the  department  meets  an  emer- 
gency she  will  call  first  the  intern  on  duty,  then  the  superintendent  of  the  training- 


348  OPERATION    OF   THE    HOSPITAL 

school.  In  an  extreme  case  she  will  call  the  attending  physician  directly  to  save 
time. 

The  nurses  conducting  a  labor  must  be  gloved  and  gowned. 

Graduate  Nurses. — Graduate  nurses  on  duty  in  the  maternity  department  must 
consider  themselves  subject  to  the  same  rules  as  those  governing  the  pupil 
nurses. 

They  will  take  orders  from  the  head  nurse  of  the  department,  and  will  report 
to  her  any  unusual  or  abnormal  condition  in  either  mother  or  child  in  their  care. 

In  an  emergency,  the  graduate  nurse  in  charge  of  a  patient  may  report  directly 
to  the  physician  in  charge  of  the  case  if  she  is  unable  to  secure  the  presence  of  an 
intern  promptly.  After  calling  the  physician  she  must  report  the  emergency  to 
the  head  nurse. 

On  being  summoned  to  the  maternity  department  to  take  charge  of  a  case 
the  graduate  nurse  must  first  report  to  the  superintendent  of  the  training-school, 
and  then  to  the  head  nurse  of  the  department. 

The  graduate  nurse  will  not  take  charge  of  her  patient's  delivery  except  on 
express  request  or  invitation  of  the  head  nurse. 

Graduate  nurses  will  consult  the  head  nurse  of  the  department  before  going 
off  duty  or  accepting  relief. 

Technic  of  the  Department. — Before  Labor. — Vaginal  examination  on  waiting 
women  must  be  made  once  only  except  in  emergency,  and  then  with  same  pre- 
cautions as  in  labor. 

Measurements  of  pelvis,  inspections  of  abdomen  and  breasts,  must  be  accurately 
made  immediately  upon  the  admission  of  a  patient,  and  the  finding  recorded  in 
detail. 

Urinalysis  must  be  made  on  all  waiting  women  at  least  three  times  a  week, 
and  oftener  if  necessary. 

History  in  detail,  with  all  external  measurements,  should  be  secured  in  all 
private  cases,  when  consent  of  patient  can  be  had,  and  the  same  accurately  recorded. 

Soapsuds  enema  must  be  given,  and,  if  the  patient  is  in  labor,  she  will  use  jar, 
and  if  not,  use  toilet.  After  bowel  movement,  give  the  patient  a  full  bath  unless 
membranes  are  ruptured  or  her  condition  is  too  serious,  in  which  case,  and  comple- 
tion of  labor  not  imminent,  give  bath  with  seat  in  the  tub. 

If  the  patient  is  in  labor  and  the  membranes  are  ruptured  she  must  be  imme- 
diately put  to  bed,  unless  otherwise  ordered. 

Never  catheterize  unless  ordered.  Never  use  glass  catheter  on  patient  in  labor; 
catheterize  under  running  water  if  possible. 

Have  patient  urinate  in  clean  jar  as  soon  as  admitted;  note  quantity,  color, 
and  odor.  Save  entire  amount  for  laboratory  examination.  Scrub  patient's 
hands  and  the  arms  up  to  the  elbows,  clean  and  trim  finger-nails  and  also  toe-nails 
if  possible. 

Never  touch  genitals,  instruments,  or  linens  unless  hands  are  sterile. 

The  Labor. — Prepare  two  sets  of  three  basins  each.  First  set:  (1)  Basin  50 
per  cent,  alcohol;  (2)  basin  1 :  4000  bichlorid;  (3)  basin  \  per  cent,  lysol.  Second  set 
for  hands  and  rubber  gloves:  (1)  Basin  1:500  bichlorid;  (2)  basin  sterile  water; 
(3)  basin  \  per  cent,  lysol  and  cotton. 

Always  have  float  in  bichlorid  basin. 

The  genitals  should  be  carefully  shaved. 

Both  hands  must  be  gloved  at  every  examination.  No  delivery  can  be  per- 
mitted in  the  department  without  gloves;  this  rule  applies  as  well  to  staff  members 
as  to  visiting  physicians  in  attendance  on  private  patients. 


Ill   I. IS     Mil;    ']')•:(  IIMCAL    DKI'AKTMENTS  34!) 

Every  stage  of  every  abnormal  labor  must  be  recorded  accurately,  and  made 
a  pari  of  the  permanent  record  of  the  ease. 

Never  leave  a  patient  while  in  labor.     She  must  be  constantly  attended,  to 

guard  against  hemorrhage,  eclampsia,  ruptured  uterus,  etc. 

Record  pains  every  hour,  as  to  frequency,  duration,  and  character. 

Record  every  examination  during;,  as  well  as  before,  labor,  by  whom  made  and 
finding. 

Vaginal  discharge  during  labor  must  be  accurately  recorded  as  to  color,  quantity, 
and  character. 

There  should  be  as  few  examinations  as  possible,  and  always  under  extreme  pre- 
cautions. 

Record  fetal  heart  sounds  every  hour  as  to  frequency,  character,  and  location. 

The  head  should  be  delivered  with  patient  on  her  side.  The  third  stage  of  labor 
should  not  be  interfered  with  for  thirty  minutes  unless  for  some  very  valid  reason, 
such  as  hemorrhage,  impending  death,  etc. 

If  patient  is  bearing  down  when  she  ought  not  to,  place  her  on  her  side;  to  hold 
her  hack  interlock  fingers  of  both  hands,  cover  genitals  with  hands  in  rubber  gloves. 

Cover  genitals  of  patient  in  labor  with  sterile  pads.  Touch  these  pads  only  at 
edges  and  with  sterile  hands.    Keep  genitals  clean  with  §  per  cent,  lysol. 

All  linen  and  clothing  of  every  sort  coming  in  contact  with  patient  in  labor  must 
be  sterilized. 

After  Delivery. — Mother  and  babe  must  be  immediately  and  carefully  tagged 
by  numbered  sewing  tape  on  wrist  of  each. 

The  babe  and  placenta  must  be  examined  and  measured  at  once,  and  findings 
accurately  described  as  a  part  of  the  permanent  record  of  the  case. 

Alter  birth  of  child  patient  should  be  assisted  to  turn  on  back  from  side,  with 
her  knees  closed,  and  the  nurse's  hands  on  fundus  uteri.  Fundus  should  be  held,  not 
manipulated,  however,  for  thirty  minutes.  Then,  and  not  until  then,  accoucheur 
should  deliver  placenta. 

Fundus  should  be  held  for  another  thirty  minutes  before  putting  abdominal 
binder  on.  If  bleeding  is  in  the  least  profuse,  nurse  should  report  same  to  head  nurse 
at  once,  certainly  before  applying  binder;  to  do  so,  however,  she  must  not  let  go  her 
hold  on  the  fundus. 

One  dram  of  ergot  is  given  to  all  patients  immediately  after  delivery  of  child, 
and  5  minims  should  be  given  to  all  prirniparse  every  six  hours  for  three  days 
postpartum. 

Care  of  the  Mother. — Nurses  ought  first,  in  taking  care  of  the  mother,  attend 
to  breasts,  then  give  enema  if  directed,  then  clean  parts  again  and  apply  hinder. 
An  enema  ought  not  to  be  given  to  a  delivered  woman,  however,  unless  specially 
ordered  by  the  physician. 

The  breasts  should  he  placed  in  the  breast-binder  after  the  first  nursing,  which 
should  occur  about  eight  hours  after  the  birth  of  the  child. 

Nipples  should  he  cleaned  before  nursing  with  boric  solution.  Hands  of  nurse 
or  patient  should  never  touch  nipples,  nor  should  they  be  touched  by  clothing. 
They  should  he  kept  covered  with  sterile  cloth. 

Temperature,  pulse,  and  respiration  of  the  mother  should  he  taken  and  recorded 
three  times  a  day,  and  oftcner  if  necessary. 

Diet  of  patient  should  be  light  soft  diet  for  two  days.  After  that  generous  diet, 
avoiding  alcoholics  and  fruit. 

Patients  should  not  rise  until  ninth  day;  then  out  of  bed  if  condition  permits. 

Each  patient  should  have  her  own  nipple  shields  and  boric  solution  pan. 


350  OPEEATION    OF   THE    HOSPITAL 

Always  keep  patient's  knees  together  when  turning  in  bed. 

Empty  bowels  on  third  day. 

Full  bath  should  not  be  allowed  until  after  three  weeks.  Until  then  use  bed- 
bath,  sponge,  etc. 

Vulval  pads  must  always  be  changed  before  the  outside  has  become  moist. 

Every  patient  must  be  examined  before  leaving  the  hospital,  and  findings  ac- 
curately described  as  a  part  of  the  permanent  record. 

No  patient  with  the  least  departure  from  normal  must  be  allowed  to  leave 
until  the  attending  physician  has  been  notified  of  the  facts  and  has  approved  the 
discharge.  In  such  case,  the  facts  with  the  physicians'  decision  must  be  stated  on 
the  record. 

Care  of  the  Baby. — Eyes. — Immediately  after  birth  of  babe,  holding  babe  on 
lap  with  eyes  looking  upward,  drop  one  drop  of  2  per  cent,  solution  of  silver  nitrate 
into  each  eye,  then  following  with  a  flushing  of  normal  saline,  always  using  sterile 
cloths. 

Cleanse  eyes  daily  with  2  per  cent,  boric  acid  solution,  wiping  toward  nose. 

Cord. — Dress  cord  daily  with  10  per  cent,  salicylic  acid  in  starch,  using  sterile 
lint  and  flannel  bandage.  Always  cover  babe's  face  when  powdering  cord.  Keep 
cord  dry. 

Temperature. — To  be  taken  per  rectum  at  birth  and  twice  daily  thereafter, 
a.  m.  and  not  earlier  than  4  p.  m. 

Weight. — Weigh  immediately  after  birth  and  once  daily  thereafter  before  bath 
and  morning  feeding;  care  should  be  taken  to  see  that  same  weight  of  clothing  is 
used  with  each  weighing. 

Bath. — The  first  bath  is  to  be  of  sterile  lard.  Afterward  a  daily  sponge  bath 
until  cord  is  off  and  umbilicus  dry;  then  a  daily  tub  bath,  98°  F.,  disinfecting  tub 
with  5  per  cent,  phenol  before  each  bath.  Nurse  to  scrub  hands  with  green  soap 
and  disinfect  with  bichlorid,  1 :  5000,  before  each  bath. 

Once  daily  after  morning  baths  boil  all  tubs  and  basins  used  in  nursery.  If 
babe  is  circumcised  give  daily  sponge-bath  until*  healed. 

After  lard  bath  finish  dressing  babe  and  place  on  side  between  blankets.  Keep 
head  covered  and  lowered  for  from  twelve  to  twenty-four  hours.  Then  place  in  its 
own  bed,  numbered  same  as  tape  on  wrist  of  mother  and  babe.  Always  place  babe 
in  its  own  bed. 

Never  put  hot-water  bags  next  to  any  part  of  a  babe. 

Mouth. — Look  into  mouth  morning  and  evening.  Never  wash  mouth  unless 
ordered  to  do  so. 

Bowels. — Note  time  of  first  stool  and  urination.  Babe  should  have  at  least 
two  stools  daily. 

Circumcision  dressing  to  be  changed  once  daily  or  oftener  if  necessary. 

Feeding. — Put  babe  to  breast  eight  hours  after  birth  and  once  again  during 
first  twenty-four  hours — afterward  nursing  every  three  hours  during  day,  not 
waking  at  night  unless  ordered.  Give  sterile  water,  1  to  2  ounces,  twice  every 
twenty-four  hours. 


THE  SURGICAL  OPERATING-ROOMS 

If  there  is  to  be  competent  surgery  in  an  institution,  and  if  the  best  interests 
of  patients  are  to  be  conserved,  there  must  be  definite  rules  for  the  conduct  of  the 
department,  no  matter  whether  the  operators  be  exclusively  staff  members  or  mem- 
bers of  the  profession  at  large  in  the  community. 

Nearly  every  surgeon,  and,  indeed,  nearly  every  medical  practitioner,  in  what- 
ever branch,  thinks  his  own  case  at  hand  is  a  very  special  one  and  entitled  to  the 
right  of  way  over  all  others.  These  men  are  right,  and  it  is  according  to  the  highest 
ideals  of  the  profession  that  they  should  feel  so.  But  a  still  larger  duty  devolves 
on  the  institution  management,  that  has  for  its  end  the  best  possible  conditions 
surrounding  every  case  coming  for  surgical  care,  and  such  conditions  cannot  be 
achieved  by  granting  special  concessions  to  one  or  a  few  men  at  the  expense  of  all 
the  others.  Hence,  the  very  first  necessity  in  the  proper  conduct  of  a  surgical  de- 
partment is  to  place  every  operator  on  the  same  plane,  so  that  each  one  shall  have 
every  facility  of  the  institution  for  the  care  of  all  his  patients,  rich  and  poor  alike, 
and  all  the  time. 

Ordinarily  it  will  not  be  an  easy  thing  to  hold  a  rigid  rein  over  busy  men,  many 
of  whom  will  aggressively  make  demands  for  special  service  and  extra  time  and  more 
nurses  and  assistants  than  the  institution  affords,  and  oftentimes  for  more  than  there 
is  any  real  need ;  and  it  may  be  suggested  that  the  only  way  to  take  the  burden  of 
such  rigorous  rules  off  the  operating-room  heads  and  off  the  shoulders  of  the  super- 
intendent of  the  institution  is  to  place  the  responsibility  on  the  surgeons  themselves 
by  having  the  staff  adopt  the  rules  by  formal  action,  and  this  action  can  be  clinched 
by  the  approval  of  the  board  of  directors  or  trustees.  Men  wall  oftentimes  approve 
a  course  of  conduct  in  the  abstract  at  a  time  when  there  is  no  case  in  point,  when 
they  will  not  be  so  reasonable  in  the  absence  of  such  formal  rule  when  they  and 
their  patients  are  the  particular  objects  of  the  rule  in  some  special  emergency. 

Under  the  head  of  Hospital  Rules,  to  be  found  preceding,  we  will  include  rules 
for  the  surgical  operating-rooms.  Just  now,  let  us  take  up  the  preparation  of 
material  and  the  general  conduct  of  the  department, 

PREPARATION  OF  MATERIAL 

Gauze,    Bandages,   Drum   Material 

Sponges  and  Plain  Gauze. — There  are  two  kinds  of  sponges — gauze  strips  and 
laparotomy  sponges. 

Gauze  strips  are  made  8  inches  wide  anil  1  yard  long,  the  width  of  the  material. 
These  arc  used  for  mopping  until  the  peritoneum  is  opened,  when  laparotomy 
sponges  are  used.  The  gauze  strips  are  to  be  tied  in  packages  of  U>  (ten),  to  be 
counted  by  two  nurses,  and  name  of  each  nurse  on  a  slip  of  paper  and  left  in  pack- 
age. The  bundles  of  10  are  tied  in  unbleached  muslin  squares,  16  by  16,  and 
marked  "Ten  (10)  gauze  sponges."  They  are  then  washed  and  boiled  with  Labar- 
raque  and  soap  for  one  hour,  followed  with  sterilization  for  forty  minutes. 

351 


352  OPERATION    OF   THE    HOSPITAL 

Laparotomy  Sponges. — Laparotomy  sponges  are  made  in  three  sizes:  11  inches 
square  (5);  8  inches  square  (4);  4  by  7  inches  (1-stitch  sponge). 

These  sponges  are  made  eight  thicknesses.  The  edges  are  whipped,  and  the 
sponge  is  then  quilted  across.  On  one  corner  of  every  sponge  there  is  a  tape  12 
inches  long,  used  for  hanging  on  sponge  rack.  These  sponges  are  always  used  wet, 
with  warm  normal  salt  solution,  110°  or  112°  F. 

Making  up  Sponge  Drum. — Sponge  drums  contain  20  bundles  gauze  strips  (10 
sponges  in  each  bundle),  8  bundles  laparotomy  sponges  (10  sponges  in  each  bundle), 
and  two  long  packs. 

Hysterectomy  Gauze. — Cut  gauze,  20  inches  by  1|  yards.  Fold  until  gauze  is 
2|  inches  wide.  Attach  black  silk,  No.  18,  to  inner  end  of  roll.  This  gauze  is  done 
up  in  blue  paper,  marked  "hysterectomy  gauze,"  and  sterilized  for  forty  minutes 
for  three  successive  days,  10-20-10. 

Long  Pack. — The  long  pack  is  5  yards  long  by  the  width  of  gauze,  folded  4-ply. 

Laparotomy  Binder  Package. — The  laparotomy  binder  package  is  made  up  as 
follows : 

(1)  Three  gauze  strips,  7  inches  wide  and  1  yard  long,  are  folded  three  times, 
making  three  pads  of  8  thicknesses  each,  about  4  by  7  inches. 

(2)  Three  pads,  made  up  of  pieces  of  gauze  12  inches  wide  and  1  yard  long,  folded 
into  four  thicknesses,  making  a  pad  8  by  12. 

(3)  Combination  made  up  of  two  pieces  of  gauze,  14  inches  wide  and  10  inches 
long,  on  each  side  of  heavy  cotton  wadding. 

These  are  all  rolled  in  the  laparotomy  binder,  with  the  small  ones  inside  and  the 
larger  ones  outside.  They  are  enclosed  by  the  wadded  pad,  and  over  all  is  the 
binder,  so  that  when  the  package  is  opened  they  can  be  reached  in  the  proper 
order.     Sterilize  10-20-10. 

Contents  of  the  Laparotomy  Drum. — Ten  towels;  4  large  sheets;  1  small  sheet; 
1  stomach  sheet;  1  pillow  case;  10  towels;  4  gowns;  1  sheet;  2  towels. 

These  are  put  in  top  downward,  so  that  when  the  drum  is  opened  the  first  articles 
will  be  two  towels  for  wiping  nurses'  hands;  next,  one  sheet  for  covering  table,  allow- 
ing the  gowns  and  towels  to  be  laid  out  for  the  surgeon  and  his  assistants;  then 
the  sheets  for  covering  patient,  who  is  brought  into  the  room  prepared  and  anes- 
thetized.    At  the  bottom  are  ten  towels  for  protection  of  the  field  of  operation. 

Sterilization  for  Laparotomy  Drum. — Vacuum,  10;  steam,  20;  vacuum,  10. 

Formula  Gauze. — There  are  three  kinds  of  formula  gauze:  Iodoform,  wide  and 
narrow;  viaform,  wide  and  narrow;  xeroform,  wide  and  narrow. 

The  wide  gauze  is  cut  1|  yards  by  9  inches,  8  strips  to  3  yards.  The  narrow 
gauze  is  cut  If  yards  by  4  inches,  18  strips  to  3  yards. 

Wide  and  narrow  iodoform,  iodoform  Mikulicz  drain,  and  iodoform  selvedged  are 
prepared  with  the  following: 

Iodoform 27  gm 

Glycerin 60  c.c.  75  gm 

Alcohol 210  c.c.        168  gm 

Sterile  water 90  c.c.  90  gm 

Gauze 130  gm 

This  makes  a  little  over  5.5  per  cent.,  allowing  for  inequalities  in  gauze,  etc. 

Wide  and  narrow  viaform  are  prepared  with  the  following: 

Viaform 27  gm 

Glycerin 60  c.c.  75  gm 

Alcohol 210  c.c.  168  gm 

Sterile  water 90  c.c.  90  gm 

Gauze 130  gm 


THE  SURGICAL   OPERATING-ROOMS  '■>■'<■'• 

Wide  ;md  narrow  xeroform  are  prepared  with  the  following: 

Xeroform 27  gm. 

( ilycerin 60  c.c.  75  rim. 

Alcohol 210  c.c.         168  gm. 

Sterile   water 90  C.C.  90  gm. 

( iauze 130  gm. 

Bandages. — Spica  Bandages. — The  muslin  for  spica  bandages  is  cut  10  yards 
long  by  4  inches  wide,  then  kept  in  a  roll.     It  is  not  sterilized. 

Plaster-of-Paris  Bandages. — Plaster-of-Paris  bandages  are  cut:  Two  inches  by  ii 
yards;  3  inches  by  (>  yards;  4  inches  by  6  yards. 

( Jut  wadding  is  rolled  on  before  the  plaster  of  Paris  is  put  on  in  any  of  the  fol- 
lowing sizes:  2-inch  by  two  lengths;  3-inch  by  two  lengths;  4-inch  by  two  lengths. 

SOLUTIONS 
LabarraqtM : 

12  ounces  chloric!  of  lime  and  6  pints  cold  water. 

16  ounces  soda  and  2  pints  boiling  water. 

After  stirring  each  solution  thoroughly  allow  them  to  settle.  Strain  and  pour  together. 
Then  strain  through  filter-paper.     Keep  in  glass-stoppered  bottles. 

Schleich: 

Formula  No.   i. 

Cocain  HC1 2 

Morphin 02 

Sodium  chlorid .2 

Aqua  dest 100.0 

Formula  No.  2. 

Cocain  HC1 1 

Morphin 02 

Sodium  ehlor .2 

Aqua  dest 100.0 

Formula  Aro.  3. 

Cocain  HC1 1 

Morphin 005 

Sodium  chlorid .2 

Aqua  dest 100.0 

Harrington: 

Commercial  alcohol 640  c.c. 

Hydrochloric  acid 60  c.c. 

Water 300  c.c. 

Corrosive  sublimate 0.S  gr. 

Hi  latin  (2  per  cent.): 

Knox  gelatin 20  gm. 

Normal  salt  solution 1000  gm. 

Dissolve  gelatin  in  140  c.c.  salt  sol.  Add  sod.  hydrox.  sol.,  few  drops,  until  it  turns  red 
litmus  blue.     Add  remainder  of  salt  sol.  and  heat  to  boiling. 

I'll,  1  rscli: 

Boric  acid 210  gm. 

Salicylic  acid 40  gm. 

Tr.  ferri  chlorid q.  s. 

Dist.  water  to  make 4000  gm. 

Dissolve  the  acids  in  the  water  and  add  of  tr.  ferri  chlor.  to  make  purple  color. 

Bichlorid: 

Bichlorid  1 :  6000  is  the  strength  in  general  use  in  operating-rooms. 

2 '._,  ounces  of  the  1:500  solution  to  1  quarl  sterile  water  makes  a  1:6000. 

10  ounces  of  the  L :  500  solution  to  l  gallon  water  makes  1 :  6000. 

30  ounces  of  the  1  :  501)  solution  for  one  of  the  plungers,  which  holds  i!  gallons. 
23 


354  OPERATION    OF    THE   HOSPITAL 

Boric  Acid  Saturated  (5  per  cent.): 

Boric  acid  crystals  to  gallon  of  water. 

Iodin: 
Lysol: 

Use  15  c.c.  to  sufficient  water  to  make  1000. 

For  \]/2  per  cent,  use  !}•£  ounces  to  quart  of  water. 


Ringer's: 

Potassium  chlorid 2.4 "|  .  ,            ....... 

Calcium  chlorid 7.2    4  °-C;  *°Aa W 

Aqua  dest 120.0  '     normal  salme- 


^"Uc.c. 
3.0  J     non 


Locke's: 

Sodium  chlorid 0.9 

Sodium  bicarbonate 0.02 

Calcium  chlorid 0.024 

Potassium  chlorid 0.03 

Four  c.c.  to  1000  c.c.  of  normal  saline. 

Carbolic  Acid  (5  per  cent.): 

Carbolic,  86.4;  232  c.c.  to  4000  c.c.  of  water. 

Bela-eucain: 

Beta-eucain 0.1 

Sodium  chlorid 0.8 

Aqua  dest 100.0 

Sterilization  of  Solutions: 

Cocain,  any  per  cent. 

Beta-eucain. 

Schleich  solutions. 

Ringer's  solutions. 

Locke's  solutions,  etc. 
Put  cotton  stoppers  in  bottles.     Place  in  basin  of  warm  water  (with  corks).     Boil  over  flame 
for  thirty  minutes.     Replace  sterile  corks  and  label. 

Temperature  of  Solutions: 

Basins  (ordinary  irrigating) 108°  F. 

Intraperitoneal  salt  solution 108°  F. 

Intra-uterine  douches 115°-120°  F. 

Silk   and   Silkworm,    Horsehair,   Melted   Wax,   Etc. 

Horsehair. — Boil  for  ten  minutes.     Keep  in  sterile  absolute  alcohol. 

Preparation  of  Silkworm. — Color  with  saturated  solution  pyoktanin;  rinse 
well;  boil  ten  minutes;  keep  in  alcohol  95  per  cent. 

Black  and  White  Silk. — Boil  for  ten  minutes.  Dry  thoroughly.  Put  up  in 
small  envelopes.     First  wrap  in  paper.     Sterilize  5-10-5  three  successive  days. 

Black  Waxed  Silk. — Boil  in  carbolic  5  per  cent,  to  remove  dye  for  ten  minutes. 
Dry  and  rinse  thoroughly.  Wind  on  cards.  Dip  in  (sterile)  melted  beeswax  and 
carbolic  10  per  cent.  Wrap  in  waxed  paper.  Seal  in  clasp  envelopes.  Sterilize 
same  as  white  silk. 

Melted  Wax  for  Silk. — Carbolic  10  per  cent.;  pure  beeswax. 

All  Silk  Sterilized. — Vacuum,  5;  steam,  10;  vacuum,  5.  Boil  for  three  suc- 
cessive days. 

Horsley's  Wax. — Salicylic  acid,  1;  olive  oil,  1;  beeswax,  7.  Boil  one  hour. 
Strap  jar  with  adhesive. 


the  8uhgical  operating-rooms  '■'•'>'> 

Rubber   Goods — Care   of 

Rubber  Tissue  and  Oiled  Muslin. — Soak  in  bichlorid,  1:  500  for  thirty  minutes. 
Dry  in  sterile  towel.     Place  in  sterile  cloth. 

Sterilization  of  Catheters. —  Urethral  and  Prostatic. — Place  in  formalin  40  per 
cent,  for  one  hour.     Seal  with  adhesive.     Rinse  in  sterile  running  water. 

Drainage    (Various) 

Bullet  Drains.— Light-weight  rubber  dam  about  4  by  7,  covered  with  wide  iodo- 
form gauze,  and  a  piece  of  small  drainage-tubing  just  tacked  to  the  center  of  the 
rubber  dam. 

Jacket  Drain. — A  piece  of  j-inch  rubber  tubing  cut  spirally,  and  two  pieces  of 
iodoform  selvedged,  inserted  in  the  center  of  the  tube.  It  is  then  wTapped  with 
iodoform  selvedged  and  covered  with  rubber  tissue. 

Cigarette  Drain. — A  piece  of  j-inch  tubing,  perforated,  wrapped  with  iodoform 
selvedged,  and  covered  with  rubber  tissue. 

Soap 

Marble-dust  Soap. — Cut  rosin  soap,  750  grains;  warm  water,  1500  grains. 
Melt  and  boil  for  one  and  one-half  hours.  Add  wax  and  stearin  paste  of  each  150. 
Lastly,  add  marble  dust,  7000  (15  pounds).     Sterilize  when  boiling. 

Green  Soap. — A  fair  grade  of  green  soap  is  made  mostly  of  cotton  seed  and  corn 
oil,  softened  by  as  much  linseed  oil  as  the  prices  proposed  can  stand,  and  the  soap 
is  made  slightly  alkaline  in  reaction,  and  when  bought  is  not  greater  than  38  to  40 
per  cent,  moisture,  because  otherwise  we  are  paying  an  unnecessary  amount  for 
water.  The  green  soap  for  operating  purposes  is  made  by  boiling  the  soap  with  a 
sufficient  quantity  of  water  added  to  give  the  desired  thickness.  If  it  is  to  be  used 
in  beer-mugs  or  big-mouth  bottles,  and  is  used  rather  carefully  by  the  surgeons, 
it  can  be  made  thick,  and  a  thick  soap  has  advantages.  If  it  is  to  feed  from  one  or 
another  of  the  patent  wash-basin  soap  feeders  it  wall  have  to  be  made  very  thin, 
in  order  not  to  clog  the  outlet  of  the  mechanism. 

It  is  highly  disadvantageous  to  use  a  soap  that  is  green  in  color,  which  some 
dealers  sell  on  the  reputation  that  the  color  is  from  the  natural  olives.  There  is 
no  green  soap  colored  by  olives  that  can  be  purchased  at  anything  like  a  price  that 
brings  it  within  the  reach  of  any  institution.  The  green  color  in  all  these  soaps  is 
a  grass  stain. 

The   Making    Up   of   Trays 

Amputation  Instruments 

'2  saws  (large  anil  small).  Gouges. 

2  saws  (chain  and  Gigli).  Chisels. 

Amputation  knives.  Mallet. 

2  bone-cutting  knives.  1  three-tailed  retractor. 

2  lion-jaw  forceps.  1  periostotome. 

1  bone-holding  forceps.  1  sequestrum  forceps. 

S/„ , ml  for  Cm ii  it/I  Work 

Gait's  conical  trephines.  2  bone-CUtting  forceps. 

2  hand  drills  and  points.  1   periostotome. 

Bone-gouging  Devibiss  forceps.  Saws  (chain  and  Gigli). 

1  chisel  and  gouge.  1  sequestrum  forceps. 

1  mallet. 


356 


OPERATION    OF   THE    HOSPITAL 


Emergency  Tray 


1  grooved  director. 

1  tenaculum. 

2  probes — 1  large,  1  small. 
1  needle  forceps. 

6  curved  snaps. 

6  pair  straight  snaps. 

Needle-holder. 

1  intestinal  forceps  (rubber  tip). 

12  rat-tooth  snaps. 

1  curved  forceps,  large. 

1  suture  dish. 


2  aneurysm  needles. 

2  curets. 

2  single  volsella. 

2  double  volsella. 

3  8-inch  clamps. 

4  dull  retractors. 
2  flat  retractors. 
2  sharp  retractors. 

1  Kocher  director. 

2  pair  tissue  forceps,  plain. 
2  pair  tissue  forceps  with  teeth. 
2  pair  tissue  forceps  without  teeth. 

Add  for  hernia — bladder  sound. 

Add  for  kidney  cases — pedicle  clamp. 

Add  for  gall-bladder — trocars  and  stone  curets;  1  Murphy  button;  1-inch  forceps;  have  ready 
potain  aspirator. 

Add  for  stomach  and  intestinal  cases — intestinal  and  stomach-clamps,  protected  with  rubber 
tubing. 

Curettage  Tray 

1  stone  forceps. 

4  polypus  forceps. 

1  curved  dressing  forceps. 

1  uterine  sound. 

1  medium  bladder  sound. 

3  8-inch  clamps. 

3  double  volsella. 

3  single  volsella. 


1  small  Sims'  speculum. 

1  large  Sims'  speculum. 

7  flat  retractors. 

1  intra-uterine  douche  point. 

1  large  dilator  (Goodell). 

1  small  dilator  (Sims). 

1  set  dilators  (Hegars). 

3  applicators. 

Curets,  all  kinds  and  sizes. 

Have  ready  tr.  iodin;  tr.  iodin  in  carbolic  acid;  zinc  chlorid,  50  per  cent. 


Perineorrhaphy- 

Curettage  instruments,  and 
2  tissue  forceps  with  teeth. 
2  tissue  forceps  without  teeth. 
1  long  tissue  forceps. 
6  curved  artery  snaps. 
6  straight  artery  snaps. 


-Trachelorrhaphy — Colporrhaphy 

6  rat-tooth  artery  snaps. 
1  needle  forceps. 
1  tenaculum. 

1  probe. 

2  lateral  retractors. 
4  5-inch  snaps. 


Gynecologic  Laparotomy 

All  curettage  instruments,  and 

9  8-inch  clamps. 

3  angle  clamps. 

3  straight  5-inch  clamps. 

1  uterine  sound. 

2  bladder  sounds. 

1  straight  dressing  forceps. 

1  curved  dressing  forceps. 

2  tenacula. 

1  needle-holder. 

Artery    snaps — straight,    6;    curved,    6; 
Kocher,  12. 

2  tissue  forceps  with  teeth. 

2  tissue  forceps  without  teeth. 


or  Vaginal  Hysterectomy 

1  probe. 

1  grooved  director. 
1  polypus  forceps. 
3  trocars. 

1  intestinal  forceps. 

Long  slender  forceps  for  a  ventral  fixation. 
3  pedicle  clamps. 

2  large  double  volsella. 
1  Kocher  director. 

Scissors — 1    dressing;    1    perineorrhaphy;    1 

curved;  2  angle. 
1  long  tissue  iorceps  with  teeth. 

1  long  tissue  forceps  without  teeth. 

2  lateral  retractors. 


Rectal  Vaginal  Fistula 
Small  emergency  tray,  with  curettage  instruments,  and  2  small  tissue  forceps. 


6  rat-tooth  artery  snaps. 

2  straight  artery  snaps. 

2  curved  artery  snaps. 

2  pair  tissue  forceps  with  teeth. 

2  pair  tissue  forceps  without  teeth. 

1  hemorrhoid  clamp. 


Hemorrhoids 

2  8-inch  clamps. 
Needle  forceps. 
Small  Sims'  speculum. 
Have  cautery  ready. 
6  straight  artery  snaps. 


THE   SURGICAL   OPERATING-ROOMS  357 

Tracht  olomy  Inslrurm  nts 

2  flat  retractors.  l  si  itch  scissors. 

2  sharp  retractors,  3  prongs.  2  pair  tissue  forceps  without  teeth, 
'_'  sharp  retractors,  2  prongs.  2  pair  tissue  forceps  with  teeth. 

-1  sharp  retractors,  1  prong.  1  Eustachian  catheter. 

3  knives.  2  dilators. 
1  aneurysm  needle.  2  sponges. 

1  grooved  director.  Tracheotomy  tubes,  all  sizes. 

1  probe.  2  curved  artery  forceps. 

1  curved  scissors.  2  straight  artery  forceps, 

1  angle  scissors.  Tape,  catgut,  silk,  needles,  gauze  for  packing, 

medicine-glass,  iodoform  gauze,  gauze. 

Tent  Insertion  Tray 

1  8-inch  clamp  with  safety-pin.  2  retractors. 

1  applicator.  Sterilized  tents  (all  sizes). 

1  uterine  sound.  Cut  cotton. 

1  double  volsclla.  Alcohol  lamp  and  matches. 

1  single  volsclla.  Lysol  solution,  '  per  cent. 

1  stone  forceps.  Sterile  gloves. 

1  Sims'  speculum. 

Eye  Operations 

The  surgeon  selects  his  own  instruments.  Have  ready — 

(1)  2  per  cent,  boric  in  basin  (warm).  (7)  Eye  needles. 

(2)  4  per  cent,  cocain  (sterile).  (8)  Plain  catgut,  No.  0  and  No.  1  black  silk. 

(3)  Adrenalin.  (9)  Sterile  vaselin. 

(4)  Atropin  sulphate,  1  per  cent  (sterile).  (10)  Sterile  cotton  and  bandages. 
i.'i)   Eye-pads.  (11)  Fine  sharp  knife. 

(ti)  Medicine-glasses  and  droppers. 

Nasal  Operation  Tray 
The  operator  selects  his  own  instruments  in  each  special  case.     Have  ready — 

(1)  2  medicine-glasses  and  droppers.  (5)  Posterior  tampons. 

(2)  Cocain  (the  percentage  the  surgeon  (6)  Bernway's  sponges. 

requires).  (7)  Powder-blower. 

(31  Adrenalin.  (8)  Iodoform  and  xeroform  gauze. 

(4)  Sterile  olive  oil — large  glass. 

Adenoids  and  Tonsils 

7  sponge-holders.  1  tonsil  volsclla. 

2  mouth-gags.  2  tonsil  volsella. 
1  tongue  depressor  (large).  1  tonsil  hook. 

1  tonsil  gouge.  1  large  glass. 
Adenoid  forceps.  Adenoid  sponges. 

2  Gottstein  curets.  Cut  gauze. 
2  tonsil  knives. 

Stitch  Tray 

1  pair  stitch  scissors.  1  long  artery  snap. 

1  pair  curved  scissors.  1  probe. 

2  pair   tissue   forceps    (1    with    teeth,    1  I  grooved  director. 

without).  1  sharp  retractor. 

2  pair  artery  snaps  ll  straight,  1  curved).  1  dull  retractor. 

1  scalpel. 

Venesection  Tint/ 

2  pair  artery  snaps.  1  probe-pointed  grooved  director. 

2  pair  tissue  forceps.  1  hook. 

1  pair  stitch  scissors.  1  probe-pointed  aspirating  needle. 

1  pair  small  curved  scissors.  '_'  aneurysm  needles. 

2  small  knives. 

In  test-tubes  add — 

2  aspirating  needles.  White-  silk  and  needles. 

Horse  hair  and  needles.  Catgut  No.  0  and  needles. 

Silk-worm  and  needles.  PipetS. 


358  OPERATION   OF   THE    HOSPITAL 

Also  add  to  tray — 

Sterile  towels.  2  medicine-glasses. 

Sterile  brushes.  Camels'  hair-brushes. 

Sterile  cotton.  Bandages,  all  sizes. 

Dressing  Tray 

1  curved  artery  snap.  1  small  retractor. 

2  straight  artery  snaps   (1   with  teeth,  1  sharp  retractor. 

1  without  teeth).  1  curet. 

1  plain  tissue  forceps.  1  curved  scissors. 

1  tissue  forceps  with  teeth.  1  stitch  scissors. 

1  grooved  director.  1  dressing  scissors. 

2  probes. 

Outfit  for  Cystoscopic  Examination 

2  soft-rubber  catheters,  Nos.  14  and  16.  1  large  irrigating  syringe. 

2  sterile  medicine-glasses.  1  large  sub  Q  syringe. 

2  bottles  of  glycerin.  Sterile  cotton. 

2  kidney  basins.  4  sterile  bottles  marked  "R"  (right). 

1  medium  urethral  syringe.  4  sterile  bottles  marked  "L"  (left). 

PREPARATION  OF  THE  OPERATING-ROOM 

There  are  three  large  pitchers  for  sterile  water  and  one  quart  pitcher  for  measur- 
ing bichlorid,  also  a  small  pitcher  for  making  normal  salt  solution  out  of  the  satu- 
rated solution. 

A  bundle  of  basins  is  then  brought  in,  containing  eight  large  basins  and  one 
small  one.  The  large  basins  are  15  inches  across  the  top  and  6  inches  deep.  Large 
basins  are  used  for  hand  solutions.  Small  basins  are  put  on  sponge  nurse's  table, 
to  be  filled  with  salt  solution  for  dipping  sponges. 

There  is  an  arm  plunger  20  inches  deep,  6  inches  across  the  bottom,  and  8  inches 
across  the  top,  for  operators  and  nurses  to  complete  sterilization  of  arms  and 
hands.  Sometimes  this  plunger  is  attached  to  a  revolving  stand  containing  also 
solution  basins. 

There  are  two  percolators,  to  be  filled  with  any  irrigating  solutions  designated 
by  the  operator. 

Two  or  three  large  buckets,  one  for  underneath  the  operating-table  and  others 
at  convenient  points,  for  throwing  used  linen  or  material. 

Shelf  Stand  and  Other  Furniture 

The  first  shelf  on  the  stand  contains  the  following : 

Lysol.  Alcohol  in  bichlor.  Phenol,  86.4  per  cent.  Glass  catheters.  Olive  oil. 
Glycerin.  Viaform.  Iodoform.  Iodoform  selvedged.  Pulled  iodoform.  Plain  and 
pulled  white  gauze.    Alcohol.    Ether. 

Second  Shelf. — Tr.  iodin.  Collodion.  Sal.  salt  sol.  Special  bottles.  Silkworm- 
gut.    Gloves  all  sizes. 

Third  Shelf. — Hypodermic  tray.  Camels'  hair-brushes.  Safety-pins.  Sealing 
gauze.  Vaselin.  Iodo.  vasel.  Suture  tray.  Dusting-powders,  all  kinds.  Forceps. 
Politzer  bag.    Thiersch  sol.    Bichlor.  sol.    Boric.  S.  S. 

Fourth  Shelf. — Transfusing  needles  and  tubing.  Green  soap.  Medicine-glasses. 
Glass  syringe.  Rubber  tubing.  Brushes.  Enema  points.  Connecting  points. 
Irrigating  points.     Angle  tubes. 

Two  hypodermics  are  put  on  the  hypodermic  tray  and  filled,  one  with  strychnin 
and  one  with  brandy,  before  each  operation  in  case  of  emergency. 

There  must  be  a  sponge-rack  made  to  conform  to  the  method  of  sponge  counting, 
whatever  that  method  may  be. 


THE  SURGICAL   OPERATING-ROOMS  350 

The  instrument  tray  stand. 

The  drum  stands  with  full  laparotomy  drums. 

The  anesthetic  stool. 

The  anesthetic  table  containing:  Roll  of  gauze  (4  inches)  sewed  with  black 
thread;  mouth-gag;  tongue-forceps;  small  basin;  ether  or  chloroform  in  the  original 
cans,  sealed;  ether  mask;  safety-pins  and  towel;  gas  mask  and  gas  machine  if  gas- 
oxygen  is  given;  oxygen  can  with  mouth-piece  if  gas  is  not  given. 

A  2-liter  flask  of  salt  solution,  Locke  or  Ringer,  as  preferred  by  the  surgeon,  is 
kept  sterile  at  a  temperature  of  120°  F.,  ready  for  immediate  use. 

One  small  funnel  3  inches  in  diameter  at  the  top,  which  is  used  in  case  salt 
solution  irrigation  is  to  be  poured  directly  into  the  abdomen. 

Transfusion  tray  is  kept  in  the  operating-room. 

Mouth-cloths,  head-cloths,  and  rubber  aprons  for  operator  and  his  assistants, 
including  nurses  who  must  come  into  the  atmospheric  field  of  operation. 

PREPARATION  OF  THE  PATIENT 

Have  ready — 

For  Vaginal  Scrubbing. — Eight-inch  clamp;  retractor;  scrub  basin;  gloves 
(scrub,  1  large);  gauze,  2  pieces  (1  small);  bottle  of  sterile  soap;  irrigating  tubing. 

For  Abdominal  Scrubbing. — Scrub  basin  minus  instruments  and  tubing; 
toothpick  swabs;  alcohol  and  ether  sponges;  bichlorid  towel;  gloves;  gauze. 

The  area  of  operation  is  shaved  and  scrubbed  with  green  soap  and  sterile  water 
and  cleansed  with  alcohol  and  ether.  Some  surgeons  follow  with  a  wet  bichlorid 
towel;  others  paint  the  area  with  tincture  of  iodin  and  cover  with  a  dry  sterile  towel. 
This  latter  part  of  the  preparation  is  a  matter  of  preference  on  the  part  of  the 
operator. 

Some  surgeons  prepare  all  patients  the  night  before  by  scrubbing  with  green 
soap  and  water  and  with  ether  and  alcohol  washing,  followed  by  bichlorid  wet- 
dressing,  left  on  until  time  of  operation,  when  the  usual  preparatory  room  technic 
is  employed. 

All  patients'  feet  are  tied  to  the  table  with  broad  bandages  with  padded  leather 
ankle  cuffs,  except  in  rectal  or  vaginal  operations,  one  foot  to  each  side  of  the  table. 
Patient's  hands  are  tied  with  arms  straight  to  sides,  with  wrist  straps  that  are  tied 
to  each  other  under  the  back,  the  straps  just  sufficiently  tight  to  hold  the  arms 
close  to  the  sides  to  prevent  them  from  falling  off  the  table,  but  so  that  neither 
hands  nor  arms  are  under  the  patient.  For  breast  and  neck  operations  hands  are 
held  by  assistants  and  are  not  tied.  In  all  rectal  and  vaginal  operations  the  legs 
are  held  by  assistants.  In  most  up-to-date  hospitals  straps  are  obsolete,  excepting 
in  the  preparatory  room,  before  the  anesthetic  is  started,  when  stirrups  and  straps 
may  be  used  to  save  assistants. 

Only  for  laparotomies  are  the  hands  tied  above  the  head. 

Never  tie  a  patient's  hands  until  the  anesthetic  is  started,  and  the  nurse  should 
never  leave  patient  while  anesthetic  is  being  given. 

Position  on  Table 

Laparotomy  or  Dorsal. — That  in  which  the  patient  lies  on  the  back. 

Knee-elbow. — One  in  which  the  patient  lies  upon  the  knees  and  elbows,  with 
the  head  upon  the  hands. 

Knee-chest  or  Genu  pectoral. — That  in  which  the  patient  rests  upon  the  knees 
and  chest,  with  the  arms  crossed  above  the  head. 


360  OPERATION    OF   THE    HOSPITAL 

Lithotomy. — One  in  which  the  patient  lies  on  the  back  with  the  legs  and  thighs 
flexed  and  the  knees  wide  apart. 

Sims. — One  in  which  the  patient  lies  on  the  left  side  with  the  right  thigh  and 
knee  drawn  up  and  the  left  arm  placed  along  the  back. 

Cunningham. — Position  for  kidney  work. 

Trendelenburg. — For  gynecologic  patients.  The  patient  lies  on  back  with  head 
and  foot  of  table  dropped. 

Preparatory  Asepsis 

Scrubbing  Up. — Hands  are  scrubbed  with  sterile  brush  and  soap  for  five  min- 
utes, then  nail-file  and  scissors  are  used;  Schleich  or  sandsoap  is  then  used  with 
gauze  for  ten  minutes,  scrubbing  arms  above  elbows.  This  is  followed  by  hand 
solutions,  alcohol,  60  per  cent.,  bichlorid,  1:6000  (this  in  plunger),  then  followed 
by  sterile  water.    The  whole  procedure  takes  at  least  twenty  minutes. 

Surgeons  put  on  clean  undershirt,  operating-room  trousers,  rubber  apron,  head- 
cloth,  and  mouth-piece,  with  sterile  operating-room  gown  over  all.  The  gloves  are 
helped  on  by  the  nurses. 

Instrument  nurse  has  on  sterile  gown,  sterile  gloves,  mouth-piece,  and  head- 
piece; likewise  the  sponge  nurse.    The  supe  nurse  is  not  supposed  to  be  clean. 

Operator  and  his  assistants  are  sterile,  but  anesthetist  is  not. 


RULES  FOR  NURSES 

Instrument  tray,  after  being  made  for  specified  operation,  is  put  in  to  boil  for 
half  an  hour  before  the  operation. 

When  a  drum  or  binder  package  has  been  opened  for  an  operation,  the  mate- 
rial must  never  be  used  again  until  recounted  and  resterilized  as  originally  done. 

No  ligatures,  sutures,  tendon,  or  other  material  that  has  once  been  exposed 
in  an  operation  shall  be  used  again  until  sterilized  all  over. 

All  tubing  and  sutures  are  treated  in  95  per  cent,  carbolic  acid  for  ten  min- 
utes. 

Never  force  an  instrument  together.  If  it  does  not  go  together  easily  there  is 
something  wrong. 

Oil  the  joints  of  all  the  instruments  with  alboline  each  time  they  are  used  before 
sterilizing. 

Dry  all  needles  (transfusing),  trocars,  and  snares  with  compressed  air  (Politzer 
bag). 

In  case  an  instrument  falls  on  the  floor,  always  boil  for  ten  minutes  before  using — 
never  sterilize  in  carbolic  and  alcohol. 

Count  sixty  before  removing  an  instrument  or  suture  from  carbolic  into  alco- 
hol.   Disconnect  instruments  before  putting  into  carbolic. 

The  Operation. — At  the  time  of  operation  the  sponge  nurse  counts  every  bundle 
of  sponges  as  she  opens  them. 

Used  sponges  are  picked  up  by  the  supe  nurse  and  hung  on  the  rack  for  that 
purpose,  which  contains  10  hooks  on  each  side  for  convenience  in  counting. 
Before  the  peritoneum  is  closed  the  sponge  nurse  and  instrument  nurse  count  the 
sponges  and  instruments,  and  report  to  the  surgeon  whether  all  are  there. 

Sponges  from  clean  operations  are  saved,  washed,  boiled  for  one  hour,  dried, 
and  folded.    From  pus  cases  they  are  burned. 


THK    SURGICAL   Ul'IOKATlM  i-l« )( >.MS  301 


THE  PREPARATION  OF  CATGUT 


With  the  uses  of  catgut  the  hospital  administrator  has  nothing  to  do;  thai  is 
the  province  of  the  surgeon;  but  the  suture  material  has  been  so  efficiently  devel- 
oped in  the  past  decade  that  it  now  is  standardized  and  classified,  and  it  has  attained 
such  constant  units  of  tensile  strength,  and  such  precisely  regulated  time  of  absorp- 
tion, that  the  busy  surgeon  has  been  able  to  practically  waive  his  former  duty  of 
superintending  the  details  of  its  preparation,  and  may  to  a  large  extent  content 
himself  with  knowing  definitely  the  care  bestowed  upon  this  important  factor  in  his 
success,  or,  better  still,  the  source  of  the  product. 

Most  modern  hospitals  in  which  a  considerable  amount  of  surgery  is  done  have 
given  over  the  home  preparation  of  catgut,  and  buy  their  supply  from  recognized 
experts  in  that  business.  There  are  many  reasons  for  this :  on  the  score  of  reliability 
there  can  hardly  be  a  doubt  that  a  scientifically  inspired  commercial  house,  whose 
chief  asset  is  public  confidence,  will  use  every  expedient  to  maintain  and  even  im- 
prove its  product  in  accord  with  scientific  principles;  whereas,  the  home-prepared 
article  must  constantly  be  subjected  to  the  hazards  of  handling  by  uninformed  nurses, 
who  are  frequently  changed  from  post  to  post,  further  complicated  by  the  neces- 
sarily unsystematic  procedures  and  conditions  in  the  preparation  rooms  concerning 
a  matter  outside  the  routine  of  hospital  practice;  nor  will  it  be  possible  ever  to  guar- 
antee precisely  the  same  conditions  for  any  two  days  or  any  two  batches  of  gut  in 
the  hospital;  so  even  if  the  utmost  care  and  conscientiousness  be  admitted,  without 
the  advent  of  a  single  unguarded  movement,  there  will  be  a  difference  now  and  again 
in  the  time  of  absorption  of  the  gut,  a  matter  of  the  most  vital  concern  to  the  sur- 
geon who  has  predicated  his  whole  operation  upon  the  sequel  of  events  in  the  healing 
of  the  tissues  and  the  absorption  of  the  suture  material  and  its  consequent  non- 
irritating  effects. 

If  it  be  on  the  score  of  economy — the  inexpensiveness  of  the  home-prepared 
article,  as  compared  with  the  apparently  high-priced  purchased  product — the  ad- 
vantage is  apparent  rather  than  real.  As  a  matter  of  fact,  surgeons  know  hospital 
conditions  pretty  well,  and  the  unpreparedness  of  the  institution  in  the  matter  of 
carefully  measured  processes  required  in  the  preparation  of  gut,  and  they  are 
becoming  more  and  more  reluctant  to  hazard  their  success  upon  the  unskilful  work 
of  hospital  people  in  the  performance  of  a  duty  that  must  be,  after  all,  only  a  very 
small  part  of  the  day's  employment,  and  they  will  not  take  their  important  patients 
where  they  must  use  such  material. 

In  the  free  wards  of  the  institution,  and  in  the  surgical  rooms  of  the  charity 
hospital,  there  is  another  factor  at  work,  even  if  the  welfare  of  the  patient  and  his 
safe  recovery  be  not  the  first  consideration — and  that  is,  delayed  convalescence  in 
the  event  of  catgut  infection  or  irritations  due  to  improperly  prepared  gut,  which 
amounts  almost  to  the  same  thing,  because  irritation  stimulates  an  exosmosis  of 
serum  about  a  wound,  and  this  in  turn  forms  an  almost  perfect  culture-medium 
for  those  micro-organisms  always  present  more  or  less  in  the  tissues,  and  which, 
under  proper  conditions,  eventuate  in  pus  formation.  It  costs  money  to  keep  a 
patient  in  the  hospital,  and,  whatever  may  be  the  attitude  of  the  institution  on  the 
point  of  keeping  a  pay  patient  as  long  as  possible,  it  will  not  take  very  long  for  a  free 
patient  to  consume  in  food  and  dressings  whatever  difference  I  here  may  have  been 
between  the  purchased  and  the  home-prepared  article.  Moreover,  it  frequently 
happens  that  a  whole  batch  of  catgut  is  either  spoiled  in  the  process  of  preparation 
iii  the  hospital,  or  else  is  found  to  be  unsterile  upon  culture  tests  and  must  be  dis- 
carded, which  would  also  tend  to  indicate  the  danger  of  the  whole  system,  or  fre- 


362  OPERATION    OF   THE   HOSPITAL 

quently  the  tensile  strength  is  found  to  be  so  poor  at  the  operating-table  that  strand 
after  strand  breaks,  which  has  the  disadvantage  of  trying  the  surgeon's  nerves,  in 
addition  to  the  loss  of  the  material. 

So  that,  by  either  horn  of  the  dilemma,  the  home  preparation  of  catgut  is  not 
as  inexpensive  a  proposition  financially  as  it  appears  prima  facie,  and  a  careful  analy- 
sis calls  for  the  conclusion  that  "home-made"  catgut  does  not  represent  surgical 
economy. 

Now  let  us  discuss  the  physics  of  catgut  preparation  as  it  is  conducted  by  ex- 
perts : 

The  first  question  naturally  is,  how  can  catgut  be  rendered  perfectly  sterile 
without  affecting  its  integrity  for  the  uses  to  which  it  is  to  be  put?  The  methods 
by  which  catgut  can  be  prepared  are  divided  into  two  general  classes — first  is  the 
heat  method,  and  second,  the  chemical  process. 

Of  the  chemicals  used  in  catgut  preparation  iodin  seems  at  the  present  time  to  be 
the  most  popular ;  biniodid  and  bichlorid  of  mercury  are  also  used  to  some  extent. 
The  chief  objection  to  the  chemical  method  of  catgut  preparation  is  that  the 
chemicals  produce  an  antiseptic  material,  and  the  obvious  drawback  lies  in  the  fact 
that  in  burying  the  catgut  the  surgeon  introduces  a  certain  amount  of  the  chemical ; 
or,  in  other  words,  the  tissues  must  take  care,  not  only  of  the  catgut  itself,  but  also 
of  the  antiseptic.  It  seems  only  reasonable  to  assume  that  whatever  antiseptic  is 
powerful  enough  to  destroy  bacteria  will  also  be  powerful  enough  to  destroy  leuko- 
cytes, the  great  repair  agents  upon  which  the  surgeon  must  rely. 

The  second  serious  objection  to  chemic  methods  of  preparing  catgut  is  the 
fact  that  the  chemicals  do  not  seem  to  completely  penetrate  the  strand;  this  may 
readily  be  demonstrated  by  taking,  for  instance,  a  piece  of  iodin  catgut  and  stripping 
it,  which  will  show  that  the  inside  is  yellow  instead  of  the  reddish-brown  color 
apparent  on  the  surface  of  the  strand;  the  natural  color  of  the  iodin  tincture 
is  reddish  brown,  and,  since  the  inside  of  a  piece  of  iodin  catgut  is  found  to  be 
yellow,  it  seems  apparent  that  the  sterilizing  agent  has  not  come  in  contact 
with  every  part  of  the  strand  in  any  considerable  strength.  Consequently, 
although  the  chemical  used  may  have  sterilized  the  outside,  the  "core"  is  in  the 
same  bacteriologic  condition  that  it  was  before  the  immersion  of  the  gut  in  the 
antiseptic. 

This  fact  has  been  demonstrated  in  the  Michael  Reese  Laboratory  in  the  fol- 
lowing manner:  two  strands  of  iodin  gut  were  taken  from  a  batch,  some  of  the 
strands  of  which  had  given  rise  to  slight  infections — one  of  the  strands,  picked 
under  carefully  sterile  conditions,  was  embedded  in  culture  medium;  the  other 
strand,  handled  also  under  careful  technic,  was  cut  into  j-inch  sections  and 
embedded  in  another  test-tube  of  the  same  medium.  After  fourteen  days  no 
growths  had  occurred  in  the  case  of  the  full-length  strand,  but  healthy  growths 
were  present  in  the  tube  containing  the  sectioned  gut.  This  procedure  was  re- 
peated five  times  to  avoid  technical  errors,  but  the  results  were  the  same  each  time. 
It  was  deduced  that  the  gelatinous  coat  of  the  whole  strand  had  prevented  the 
escape  of  the  micro-organisms,  but  the  cut  ends  of  the  sectioned  gut  had  permitted 
the  escape  and  subsequent  activities  of  the  bacteria.  There  is  scarcely  a  doubt 
that  persistence  to  the  point  of  solution  of  the  undivided  strand  would  have  led 
to  bacterial  growths  there  also. 

Still  another  objection  to  iodin  catgut  is  that  the  iodin  has  a  rotting  effect  upon 
the  animal  tissue,  and  the  longer  the  gut  is  left  in  it  or  the  greater  the  strength  of 
the  tincture,  the  more  marked  is  the  rotting  action  of  the  iodin.  It  may  be  well  to 
mention  here  that  catgut,  purposely  left  in  iodin  for  a  long  time,  was  found  to  have 


THE    SURGICAL   OPERATING-ROOMS  3G3 

lost  its  tensile  strength,  and,  therefore,  could  not  be  used  for  surgical  purposes, 
and  even  then  the  "core"  of  the  strand  stripped  a  clear  yellowish  color. 

With  bichlorid  of  mercury,  one  must  bear  in  mind  that  the  action  of  this  on 
albumin  or  gelatin  is  to  form  an  insoluble  albuminate  of  mercury;  the  nature  of 
catgut  being  gelatinous,  the  action  of  the  bichlorid  would  be  to  form  an  impene- 
trable albuminate;  in  other  words,  the  action  of  the  antiseptic  would  be  to  defeat 
the  very  object  intended. 

Home-made  catgut  is  prepared  in  some  hospitals  by  the  so-called  Claudius 
method,  which  calls  for  the  immersion  of  the  gut  in  a  1  per  cent,  tincture  of  iodin 
in  alcohol,  in  which  the  material  is  supposed  to  be  stored  for  eight  days.  Several 
modifications  of  this  method  have  been  suggested — some  vary  the  time,  generally  1  ly 
reducing  the  number  of  days  (to  minimize  the  rotting  effect  of  the  solution),  while 
others  vary  the  strength  of  the  tincture.  Some  prefer  an  aqueous  solution  of  iodin 
instead  of  the  alcoholic  tincture  recommended  by  ( 'laudius. 

Water  seems  to  be  the  only  liquid  which  has  the  property  of  penetrating  a 
strand  of  catgut  through  and  through,  but,  unfortunately,  water  cannot  be  used 
to  sterilize  catgut,  on  account  of  its  liquefying  action  upon  the  animal  tissues. 
Alcohol,  chloroform,  and  ether  are  other  liquids  that  seem  not  to  completely  pene- 
trate catgut. 

There  is,  howrever,  one  method  of  catgut  preparation  which  calls  for  the  boiling 
of  catgut  in  water  for  a  short  length  of  time;  to  comply  with  it,  the  catgut  must  be 
previously  hardened  by  means  of  formalin,  to  guard  against  the  softening  action 
of  boiling  water — but,  even  then,  the  No.  1  can  be  boiled  only  from  seven  to  nine 
minutes,  and  the  smaller  sizes  for  even  a  shorter  time  than  this.  In  view  of  the  fact 
that  bacteriologists  maintain  the  minimum  thermal  death-point  of  tetanus  spores 
to  be  twenty  minutes  of  wet  heat  at  212°  F.,  it  is  at  once  apparent  that  by  this 
method  it  is  physically  impossible  to  destroy  all  bacterial  organisms.  In  other 
words,  the  surgeon  who  has  his  catgut  prepared  by  this  method  allows  his  instru- 
ments to  receive  more  sterilization  than  his  catgut,  which  is  not  consistent,  because 
with  catgut  the  inside  as  well  as  the  outside  must  be  rendered  sterile,  whereas,  with 
the  instrument,  it  is  merely  a  matter  of  surface  sterilization,  and,  above  all,  the  cat- 
gut is  to  buried  in  the  tissues,  which  is  not  the  case  with  the  instruments.  Inci- 
dentally, another  serious  drawback  to  this  method  is  the  mummifying  of  the 
animal  tissue  by  the  action  of  the  formalin,  tending  to  produce  a  brittle  material. 

Since,  then,  neither  the  chemic  nor  the  wet-heat  method  is  ideal  as  well  as 
practicable,  let  us  now  consider  the  only  other  procedure  which  remains  open — 
that  is,  the  use  of  dry  heat. 

Since  organisms  that  may  be  destroyed  at  a  certain  temperature  in  wet  heal 
are  not  destroyed  at  the  same  temperature  in  dry  heat,  it  is  obvious  that  the 
temperature  must  be  raised  and  maintained  for  a  greater  length  of  time  than  would 
be  the  case  with  wet  heat;  and  again,  authorities  have  found  that  several  applica- 
tions of  dry  heat  (fractional  sterilization)  are  more  destructive  to  bacteria  than  only 
one  prolonged  application.  Dry  heat,  moreover,  not  only  goes  to  the  core  of  the 
strand,  but  an  aseptic,  non-irritant  material  is  produced,  for  there  is  no  chemical  to 
injure  the  tissues.  It  is  claimed  that,  while  the  staphylococcus  is  destroyed  in  wet 
heat  at  180°  F.  in  a  few  minutes,  it  requires  sixty  minutes  in  dry  heat  at  the  same 
temperature  (Lehniann).  With  the  tetanus  spore  the  established  thermal  death- 
point  is  considered  302°  F.  for  an  hour  in  dry  heat  (Rosenau,  Park,  and  others); 
it  has  also  been  found  that  this  organism  will  resist  284°  F.  for  as  long  as  three 
hours  (Sternberg). 

Of  course,  the  possibility  of  anthrax  in  catgut  is  well  known  as  it   i-  a  sheep 


364  OPERATION   OF   THE   HOSPITAL 

disease,  and  it  is  possible  for  spores  to  be  present  in  the  intestines.  Tetanus  being 
a  soil  disease,  the  sheep  is  quite  likely  to  act  as  a  host  to  the  spore  of  this  bacillus. 
It  is  by  no  means  a  common  thing  to  find  either  of  these  spores  in  raw  catgut  even 
before  any  sterilization  is  attempted,  which  is  a  fortunate  thing  for  those  who  use 
indifferently  prepared  catgut.  The  surgical  world  should  be  grateful  that  tetanus 
or  anthrax  infections  are  rare  with  any  kind  of  catgut,  but  there  is  a  danger,  and 
the  conscientious  surgeon  and  hospital  administrator  must  take  steps  to  eliminate 
the  possibility. 

Commercial  raw  catgut  is  surprisingly  clean,  even  before  sterilization,  and  so 
long  as  the  catgut  preparer  deals  with  clean  catgut — so  far  as  pathogenic  bacteria 
are  concerned — immersions  in  alcohol,  ether,  chloroform,  or  iodin  will  produce  ex- 
cellent results;  but  this  clean  catgut  really  would  not  need  any  sterilization  at  all, 
or,  to  put  it  more  clearly,  if  we  could  select  the  pathogenically  clean  raw  catgut 
and  use  it  as  it  is,  the  chances  for  infection  would  be  very  small. 

The  worst  result  that  might  follow  its  use  would  be  an  irritation,  perhaps, 
from  the  non-pathogenic  bacteria  present  in  it,  and  such  irritation  the  surgeon  might 
attribute  to  some  cause  other  than  the  catgut. 

The  f ollowing  methods  of  sterilization  by  dry  heat  are  used  to  some  extent : 

The  strand  of  catgut  is  placed  in  a  paraffin-paper  envelope,  placed  in  an  oven 
and  subjected  for  three  hours  to  a  temperature  of  about  250°  F.,  after  which  the 
material  is  ready  for  use.  There  are  objections  to  this  method:  first,  the  material 
has  not  been  subjected  to  a  temperature  considered  by  authorities  to  be  the  thermal 
death-point  of  tetanus  and  anthrax  spores.  Sternberg  has  found  that  tetanus 
spores  resist  284°  F.  for  three  hours,  as  mentioned  above,  while  this  method  calls 
for  only  250°  F.  for  the  same  length  of  time;  second,  by  this  method  the  material 
receives  only  one  application  of  heat,  whereas  it  seems  to  be  acknowledged  that 
three  fractional  applications  of  heat  are  necessary,  and  it  is  significant  that  most 
hospitals  sterilize  their  dressings  by  means  of  three  fractional  applications. 

Another  method  in  use  in  some  hospitals  consists  in  boiling  catgut  in  alcohol, 
the  length  of  time  and  temperature  varying  with  the  individual  operating-room 
nurse's  "technic";  some  nurses  boil  catgut  in  alcohol  without  pressure  for  an  hour; 
the  boiling-point  of  alcohol  is  170°  F.  Occasionally  the  time  is  raised  to  as  much  as 
two  hours  or  even  three  hours.  A  great  many,  however,  subject  the  alcohol  to 
pressure  in  a  steam  sterilizer,  and  run  the  temperature  as  high  as  225°  and  even  250° 
F.;  when  the  alcohol  is  subjected  to  pressure  in  this  way,  the  length  of  time  is 
generally  not  more  than  an  hour,  or  even,  in  some  institutions,  less. 

In  considering  the  efficiency  of  this  method  it  is  necessary  to  draw  a  line  be- 
tween wet  liquids  and  dry  liquids,  because  this  is  of  the  utmost  importance  bacte- 
riologically.  Water  is  a  wet  liquid — any  liquid  containing  water  is  a  wet  liquid; 
liquids  containing  no  water  are  dry.  Commercial  absolute  alcohol  (95  per  cent.) 
does  not  contain  a  sufficient  quantity  of  moisture  to  gelatinize  catgut  boiled  in  it, 
and  it  is  a  dry  liquid.  It  is  physically  impossible  to  boil  catgut  in  water  or  anything 
containing  as  much  as  15  per  cent,  or  more  of  water,  because  the  water  in  a  very 
short  time  softens  and  gelatinizes  the  animal  tissue;  therefore,  it  is  absolutely  neces- 
sary to  boil  catgut  in  a  liquid  containing  no  water,  otherwise  the  gut  will  be  soft- 
ened and,  therefore,  rendered  useless. 

Now,  then,  with  alcohol  we  have  a  dry  heat  of  170°  F.  (the  boiling-point  of  alco- 
hol) compared  with  302°  F.,  or,  if  boiled  under  pressure,  the  maximum  temperature 
obtainable  with  alcohol  is  250°  F.;  170°  F.  does  not  compare  very  favorably  with 
180°  F.,  the  thermal  death-point  of  staphylococcus  (Lehmann),  and  certainly 
neither  170°  nor  250°  F.  with  dry  heat  are  sufficient  to  destroy  tetanus  spores  in  the 


THE    si  RGICAL   OPERATING-ROOMS  3<>5 

time  usually  allowed  by  hospitals  thai  prepare  their  own  catgut.     It  is  evident, 

therefore,  that  the  alcohol  methods  are  not  safe  from  the  bactcriologic  standpoint, 
measured  by  recognized  bacteriologic  authorities. 

There  are  a  number  of  concerns  that  have  the  confidence  of  the  medical  pro- 
fession in  the  preparation  of  catgut.  One  of  these  is  Van  Horn  and  Sawtell,  a  firm 
that  has  many  adherents,  and  whose  catgut  products  are  regarded  as  standard  by  a 
large  section  of  the  profession.  The  Michael  Reese  Hospital  employs  the  catgut 
of  this  firm  exclusively,  and  we  are,  therefore,  taking  the  liberty  of  accepting  its 
methods  of  catgut  sterilization  as  illustrative  of  the  expert  preparation  of  efficient 
catgut. 

After  the  necessary  pre-preparation  of  the  gut  the  strand  is  rolled  up  and  placed 
in  a  previously  sterilized  tube,  one  end  of  which  is  sealed  and  the  other  left  open; 
in  this  way  reinfection  of  the  gut,  due  to  its  being  touched  by  human  hands,  is 
impossible  after  the  process  commences.  In  the  oven  it  receives  an  application 
of  dry  heat  for  a  period  of  four  and  one-half  hours,  the  temperature  gradually 
reaching  a  maximum  of  240°  F.,  and  cumol,  one  of  the  benzine  series  (used  because 
it  allows  of  a  high  temperature  and  does  not  soften  the  catgut) ,  is  placed  in  the  tubes 
with  the  catgut  and  also  surrounding  the  tubes.  From  240°  F.  the  temperature  is 
gradually  raised  to  not  less  than  310°  F.,  at  which  minimum  it  is  kept  for  two  hours. 
On  the  following  day  the  cumol  is  poured  off,  and  another  application  of  240°  F. 
for  an  hour  is  made;  this  application  not  only  forms  the  third  fraction  of  the  process, 
but  evaporates  the  cumol  from  the  surface  of  the  strand.  Then  the  preserving 
fluid  is  placed  in  the  tube  with  the  strand  under  aseptic  precautions,  after  which 
the  tube  is  sealed. 

On  the  following,  or  fourth  day,  to  guard  against  any  possible  air  contamination 
which  may  have  taken  place  during  the  filling  of  the  tube  with  the  preserving  fluid 
in  spite  of  the  precautions,  the  sealed  tube  is  placed  in  the  steam-pressure  sterilizer 
and  subjected  under  pressure  to  270°;  F.  for  one  hour,  and  this  is  repeated  on  the 
fifth  day,  thus  making  five  fractional  sterilizations,  three  of  which  take  place  before 
the  sealing  of  the  tube  and  the  concluding  two  after  the  sealing. 

Kangaroo  tendons  are  taken  from  the  tail  of  the  kangaroo,  anel,  after  the 
necessary  cleansing  preparation,  are  sterilized  in  precisely  the  same  way  as  catgut. 

Chromicized  catgut  is  made  by  treating  catgut  with  chromic  acid  for  varying 
periods  in  proportion  to  the  time  it  is  intended  to  resist  absorption  in  the  tissues. 
It  is  obtainable  in  resistances  of  ten,  twenty,  thirty,  and  forty  clays,  referring  to  the 
length  of  time  the  catgut  can  be  depended  upon  as  a  suture— in  muscle  tissue  before 
absorption  begins.  After  the  catgut  has  been  treated  in  chromic  acid  for  the 
proper  length  of  time  the  acid  is  eliminated,  and  the  sterilization  proceeds  by  the 
fractional  method  described  above. 

RUBBER  GLOVES 

Gloves  are  so  essentially  appurtenances  of  the  operating-  and  dressing-rooms  that 
we  shall  be  justified  in  considering  them  apart  from  the  other  rubber  goods  of  the 
institution. 

There  is  no  concensus  of  opinion  as  to  just  how  far  rubber  gloves  should  be  used 
in  institutions.  There  are  many  hospitals  that  do  not  offer  their  surgeons,  obstet- 
ricians, and  gynecologists  rubber  gloves,  and  some  institutions  require  operators  to 
furnish  their  own  gloves  when  they  wish  to  wear  them,  and  there  is  rather  a  dispo- 
sition everywhere  to  make  operators  furnish  their  own  gloves,  not  because  institu- 
tions regard  gloves  as  a  luxury,  but  rather  because  operators  an'  prone  to  go  just 


366  OPERATION   OF   THE   HOSPITAL 

one  step  farther  than  most  administrative  officers  feel  justified  in  following;  that 
is,  if  the  institution  begins  to  furnish  gloves  and  to  mend  those  that  are  pricked 
with  a  needle  or  very  slightly  torn,  the  operators  are  likely  to  offer  the  objection 
that  infectious  matter  may  catch  at  the  point  of  the  mend,  and,  therefore,  they  ask 
for  new  gloves  for  every  operative  procedure.  Also,  nowadays  many  operators 
go  to  the  extent  of  demanding  clean,  new  gloves  for  every  one  of  a  series  of  clean 
operations  and  for  each  dressing.  Other  operators  require  not  only  their  first  assist- 
ants, but  all  the  nurses  engaged  in  the  operating-room  to  wear  new,  sterile  gloves. 

It  seems  a  good  deal  of  this  glove  technic  borders  closely  upon  faddism;  a  sterile 
glove  should  be  a  sterile  glove,  whether  it  is  brand  new  or  has  a  mend  in  it;  if  the 
glove  is  not  sterile,  the  mend  will  not  be  sterile,  and  if  it  is  sterile,  then  the  mend  is 
sure  to  be  also  sterile,  and  usually  the  point  of  a  mend  in  a  glove  is  stronger  than 
any  other  part,  so  far  as  its  likelihood  to  break  is  concerned.  It  is  an  illuminating 
fact  that  surgeons  who  must  buy  their  own  gloves  do  not  carry  their  demands  very 
far  into  faddism,  and  can  usually  get  along  with  far  fewer  gloves  than  those  to  whom 
the  institution  supplies  them. 

Then  there  is  the  question  of  the  lightness  or  heaviness,  smoothness  or  rough- 
ness of  gloves,  the  length  of  the  gauntlet,  the  reinforcement  and  taper  of  the  fingers. 
Choice  in  all  these  particulars  is  individual  to  the  operator;  some  operators,  for  in- 
stance, require  pebbled  gloves  of  the  thinnest  kind  for  laparotomies,  whereas  they 
will  require  a  smooth  glove  for  superficial  operations,  and  vice  versa.  Some 
operators  require  that  all  finger-tips  be  reinforced  and  shaped  to  the  nail,  whereas 
others  insist  on  the  very  thinnest  sort  of  finger-tips;  most  operators  who  do  deep 
surgery  require  gauntlet  gloves;  some  surgeons  require  in  all  their  work  a  very  heavy 
loose  fitting  glove,  such  as  that  commonly  used  in  postmortem  work,  where  the 
deftness  of  finger  is  not  of  prime  consideration. 

It  is  not  at  all  certain  that  any  institution,  however  rich  and  liberal,  should  be 
asked  to  furnish  all  these  various  sorts  of  gloves  for  its  attending  operators.  In  a 
certain  institution,  where  there  are  perhaps  fifty  or  more  operators  at  various  times 
in  a  large  or  small  way,  it  is  the  rule  to  furnish  each  operator  with  whatever  kind 
of  gloves  he  requires,  and  for  that  purpose  an  infinite  variety  of  gloves,  as  to  form, 
size,  texture,  and  make,  are  kept  on  hand,  and  there  is  an  immense  waste  in  this 
procedure,  because  rubber  gloves  oxidize  and  vulcanize  very  easily,  and  cannot 
be  kept  intact  and  in  serviceable  form  longer  than  a  few  weeks  at  most,  and  when 
they  undergo  this  degeneration  they  are,  of  course,  worthless,  as  they  tear  on  the 
slightest  attempt  to  put  them  on.  In  this  institution  the  glove  bill  alone  amounts 
to  $2000  to  $2500  per  year. 

The  Test  of  Gloves. — It  goes  without  saying  that  gloves  must  be  fresh  and 
comparatively  new,  and  of  the  purest  rubber,  if  they  are  to  be  useable  and  capable 
of  sterilization.  There  are  many  salesmen  who  sell  gloves  to  hospitals,-  or  attempt 
to  do  so,  but  most  of  these  people  are  mere  hucksters,  and  there  are  only  three  or 
four  firms  that  make  gloves  worthy  the  name  and  whose  goods  are  to  be  relied 
upon,  and  then  only  providing  they  themselves  offer  them  first  hand  and  under  the 
name  of  "firsts."  The  Canton  Rubber  Co.,  Faultless  Rubber  Co.,  and  Miller 
Rubber  Co.  are  practically  the  only  makers  of  rubber  gloves  that  are  worth  buying. 

There  are  only  two  tests  for  gloves  that  amount  to  anything — one  of  them  is  to 
blow  the  glove  up  until  it  is  as  thin  as  tissue  paper,  and  then  go  over  it  critically 
with  the  eye  and  finger  to  detect  weak  spots  either  in  the  finger-ends  or  elsewhere. 
There  are  sometimes  blebs  or  blisters  in  the  glove,  but  the  usual  defects  are  in  or 
between  the  fingers.  After  the  glove  is  well  blown  up  it  should  bear  a  considerable 
amount  of  pressure  as  the  hand  goes  over  it  trying  out  the  various  parts.   If  the  glove 


THE  SURGICAL   OPERATING-ROOMS  307 

has  undergone  deterioration,  due  to  oxygen  in  the  atmosphere,  such  as  will  invariably 
occur  in  the  shop-worn  gloves,  where  will  appear  sometimes  distinct  cracks,  especi- 
ally at  the  finger-ends,  but  more  generally  this  deterioration  will  be  manifest  in 
lighter  colored  specks  in  the  glove,  and  these  light  spots  arc  always  weak;  these 
spots  show  clearest  when  the  glove  is  relaxed  and  not  blown  up. 

The  other  test  for  gloves  is  hot  water  blown  into  the  glove  under  pressure  with 
a  syringe;  this  will  invariably  reveal  even  the  most  infinitesimal  needle  prick. 
The  heat  from  the  inside  will  dry  any  water  that  may  be  on  the  outside,  and  if 
some  pressure — as  for  instance,  from  a  bulb  syringe — has  been  used  in  filling  the 
glove  a  wet  spot  will  appear  wherever  there  is  the  smallest  hole;  and,  by  the  way, 
this  is  the  best  of  all  methods  of  detecting  flaws  in  gloves  after  they  have  been  first 
used  and  before  they  are  resterilized.  In  a  good  many  institutions  the  nurses  test 
their  clean  gloves  by  blowing  them  up,  covering  them  with  powder,  and  holding 
every  part  in  turn  to  the  cheek,  but  it  goes  without  saying  that  this  method  is  defect- 
ive and  open  to  many  errors. 

Sterilization  of  Gloves. — In  some  institutions  gloves  are  sterilized  by  boiling 
alone.  Of  course  this  method  is  plainly  defective  in  two  directions:  first,  boiling 
water  has  a  temperature  of  only  212°  F.,  which  will  not  destroy  a  number  of  patho- 
genic micro-organisms,  especially  the  spore  formers;  and,  secondly,  because  boiling 
water  destroys  the  rubber  very  rapidly.  Some  institutions  again  sterilize  in  live 
steam  under  a  pressure  of  15  pounds,  and  a  good  many  of  the  sterilizer  manufactur- 
ers advocate  this  method;  it  is  certainly  the  best  way  if  the  life  of  the  glove  alone 
is  under  consideration,  as  gloves  can  be  resterilized  as  many  as  six  or  eight  times  if 
vapor  sterilization  is  employed,  but  it  is  not  effective  even  at  a  pressure  of  15  pounds 
to  the  square  inch,  or  250°  F.  for  thirty  minutes,  because  gloves  heated  in  this  way, 
and  then  planted  in  one  or  other  of  the  culture-media,  have  shown  vigorous  growths 
of  micro-organisms.  In  the  Michael  Reese  Hospital  the  following  method  is 
employed: 

The  gloves  are  first  washed  clean  in  hot  water;  they  are  then  wrapped  in  cloths 
and  put  in  the  sterilizer,  and  kept  under  live  steam  at  250°  F.  for  thirty  minutes. 
The  vapor  is  then  withdrawn,  and  a  dry  heat  of  the  same  temperature  is  introduced 
for  thirty  minutes  longer.  This  last  half-hour  is  hard  on  the  glove,  but  no  culture 
has  ever  been  formed  following  it,  and  will  not  be,  unless  there  is  some  defect  in 
the  technic  of  getting  the  glove  from  the  sterilizer  to  the  culture-medium. 

"First"  and  "Second"  Gloves. — There  seems  to  be  a  good  deal  of  high  finance 
in  the  sale  of  rubber  gloves  by  the  manufacturers.  Most  makers  sell  their  "firsts" 
or  "prime"  gloves  at  prices  varying  from  $5.50  per  dozen  pairs  for  the  smaller 
smooth  gloves,  to  $7.50  for  the  larger  size  smooth  and  rough  gloves,  with  an  extra 
price  for  gauntlets  and  for  fads  of  individual  operators,  but  the  market  for  these 
gloves  is  somewhat  limited,  and  it  is  the  custom  of  manufacturers  to  sell  their  sur- 
plus as  "seconds."  These  "seconds"  are  admittedly  defective,  but  sometimes  t  hese 
defects  cannot  be  pointed  out  even  by  the  manufacturers  themselves.  Sometimes 
these  gloves  not  only  show  no  defects,  but  stand  all  the  tests  as  to  freshness  and 
first-class  quality,  and  should  be  sold  as  "surplus"  instead  of  "seconds";  at  least 
the  plea  of  "defective"  gives  the  manufacturers  warrant  to  let  the  gloves  go  at  a 
lower  price  than  "firsts"  are  held  at.  However,  glove  buyers  should  make  them- 
selves so  thoroughly  acquainted  with  all  the  tricks  in  the  glove  business  as  to  be  able 
to  buy  their  gloves  independently  of  whatever  the  manufacturers  may  say  or  offer. 
If  "seconds"  that  are  really  as  good  as  "firsts"  can  be  purchased  a  saving  of  50  per 
cent,  can  be  made.  Sometimes  a  manufacturer,  in  offering  "seconds"  that  appear 
to  be  "firsts,"  will  hint  that  perhaps  the  "seconds"  will  not  bear  resterilization  as 


368  OPERATION   OF   THE   HOSPITAL 

many  times  as  the  "firsts,"  but  this  statement  does  not  work  out  in  practice,  as  it 
is  the  experience  of  a  good  many  of  us  that  a  good  glove,  whatever  it  may  be  called 
as  to  quality,  will  wear  about  as  well,  will  stand  pricks  as  poorly,  and  will  sterilize 
as  frequently  as  any  other  good  glove. 

THE  SURGICAL  ANESTHETIC 

The  subject  of  anesthetics  for  the  operating  department  must  be  considered 
from  the  standpoint  of  the  surgeon  and  from  that  of  the  hospital  administrator. 
However,  since  both  have  the  same  ultimate  purpose  in  view,  we  shall  endeavor  to 
analyze  and  correlate  the  two  sides  of  the  problem. 

The  first  and  most  vital  question  to  be  answered  is  this:  Into  whose  hands 
shall  the  actual  administration  of  the  anesthetic  be  entrusted?  Hitherto  the  custom 
in  many  hospitals  has  been  to  detail  the  house  physicians  as  anesthetists,  allowing 
them  to  become  proficient  in  that  best  of  schools,  experience,  under  the  guidance  of 
skilled  tutors.  In  some  private  hospitals  each  operator  has  his  own  paid  anesthetist ; 
in  a  few  there  is  a  salaried  expert  anesthetist  for  all  cases,  and  in  others  an  expert 
available  for  special  cases. 

There  is  a  tendency,  manifest  with  many  surgeons,  to  employ  specially  trained 
young  women  to  administer  their  anesthetics,  but,  since  it  is  not  proposed  that  these 
operators  shall  have  had  a  competent  medical  education,  their  employment  as  a 
solution  of  the  problem  is  hardly  worth  considering,  because,  while  a  person  trained 
by  thumb-rule  may  administer  in  the  classical,  average  operation,  the  great  majority 
of  patients  will  fall  outside  the  class  of  ordinary,  and  the  conduct  of  the  anesthetic 
must  meet  the  requirements  of  the  individual  and  not  the  class.  No  two  cases 
of  pneumonia  can  be  treated  precisely  alike,  even  though  both  may  run  a  normal 
course,  nor  can  any  two  sick  people  ever  be  treated  exactly  alike.  There  are 
radical  differences  between  individuals — no  two  will  have  the  same  receptiveness  to 
certain  drugs,  and  in  the  same  way,  and  perhaps  for  the  same  physiologic  reasons, 
no  two  persons  will  take  any  anesthetic  exactly  alike.  There  are  some  medical 
men,  even  able  surgeons,  who  think  all  the  requirements  have  been  met  if  the  patient 
is  kept  relaxed  and  noiselessly  asleep  during  the  operation  and  is  put  back  to  bed 
alive.  This  philosophic  attitude  will  hardly  do  to-day,  when  the  surgeon  is  under- 
taking surgical  operations  that  call  for  the  severest  tests  upon  the  reserve  forces 
of  sick  people,  when  a  feather-weight  of  difference  may  mean  life  or  death.  What 
a  huge  percentage  of  patients  operated  upon  die  nowadays  from  postoperative 
complications — pneumonias,  uremias,  shock,  and  infections — that  just  a  little  more 
resistance  might  have  enabled  them  to  weather! 

Then  how  important  is  it  to  bring  the  patient  through  the  operation  in  the 
best  possible  shape,  and  with  the  greatest  possible  amount  of  reserve  force  for  the 
long  days  and  nights  of  hazardous  convalescence! 

It  will  not  do  any  longer  to  order  any  particular  anesthetic  for  any  given  case 
before  the  patient  goes  to  the  operating-room.  Preparations  must  be  made  for  an 
instant  change  from  gas  to  ether  and  the  reverse.  The  anesthetist  must  realize, 
from  second  to  second,  any  adverse  effect  of  the  drug  upon  the  patient,  even  to  the 
finest  shade,  and  must  be  ready  to  shift  his  mask  before  another  breath  is  drawn. 
How  negligent,  even  criminal,  it  is  to  subject  a  patient  to  the  mercies  of  a  person 
unversed  in  the  sign  and  symptom  language  of  unconsciousness.  It  is  for  these 
reasons  that  anesthetics  must  be  given  by  trained,  experienced  medical  persons, 
into  whose  hands  even  then  will  come  enough  untoward  results  to  make  it  imperative 
that  only  the  most  competent  should  be  employed. 


THE   SURGICAL  OPERATING-ROOMS  309 

In  the  Michael  Reese  Hospital  there  is  an  anesthetic  staff  of  three  physicians, 
former  interns,  two  of  whom  are  on  service  simultaneously,  and  whose  duty  it  is 
to  teach  all  new  interns  the  Michael  Reese  methods  of  administration,  remaining 
with  each  new  man  until  they  can  certify  him  as  experienced  or  shift  him  as 
impossible.  They  are  also  present  for  any  particularly  difficult  case,  ward  or 
private. 

In  cases  of  special  hazard,  or  at  the  request  of  the  operator,  the  expert  attending 
anesthetist,  himself  must  give  the  anesthetic,  receiving  remuneration  therefor. 
This  arrangement  places  the  responsibility  on  the  shoulders  of  experienced  men,  and 
results  in  a  much  better  average  of  anesthetics,  and  breeds  a  sense  of  security 
during  the  operation,  a  feeling  most  operators  will  appreciate. 

The  purpose  of  the  anesthetic  is  to  keep  the  patient  in  a  state  of  unconscious- 
ness, with  relaxation,  during  the  surgical  operation,  and  to  bring  him  out  of  the 
operation  with  the  least  possible  damage,  both  as  concerns  the  effect  of  the  anes- 
thetic itself  and  the  surgical  insult  to  the  system.  To  achieve  this  double  pur- 
pose many  of  the  best  minds  in  the  surgical  world  and  great  numbers  of  able 
laboratory  men  have  spent  vast  energy  and  deep  investigation.  We  shall  omit 
discussion  of  those  methods  which  are  still  on  trial,  and  content  ourselves  rather 
with  a  view  of  those  anesthetics  that  are  recognized  and  approved  by  the  medical 
profession. 

There  are  only  three  of  these  anesthetics — ether,  nitrous  oxid  with  oxygen,  and 
chloroform. 

Chloroform. — Chloroform  is  quickly  disposed  of.  In  this  country  and  in  the 
best  clinics  abroad,  notably  Von  Eiselsberg  in  Vienna  and  Bumm  in  Berlin,  it  has 
been  discarded  almost  entirely.  Its  use  should  be  restricted  to  those  few  cases  in 
which  ether  is  contra-indicated,  and  even  here  it  is  in  large  part  being  supplanted 
by  nitrous  oxid-oxygen.  Some  few  men  still  persist  in  its  use,  but  there  is  no  doubt 
that  its  extremely  narrow  margin  of  safety  renders  it  dangerous  in  the  hands  of 
the  average  anesthetist,  and,  although  statistics  are  most  unreliable,  all  are  agreed 
in  assigning  the  highest  mortality  to  chloroform.  Moreover,  the  recent  work  of 
Henderson,  to  be  referred  to  later,  helps  to  explain  its  dangerous  properties.  When 
used  at  all,  it  must,  of  course,  be  given  dropwise  on  the  open  mask,  always  remaining 
below  a  vapor  concentration  of  2  per  cent.  A  chloroform  anesthetic  may  be 
switched  to  ether  with  comparative  impunity,  but  the  reverse  procedure,  unless 
interrupted  by  several  moments  of  air  breathing,  may  result  in  disaster.  Finally, 
the  immunity  to  chloroform,  supposedly  possessed  by  women  in  labor,  remains 
debatable,  and  here,  also,  chloroform  is  beginning  to  be  displaced. 

Ether. — Ether  has  been  the  anesthetic  of  choice  up  to  the  present  time,  and 
rightly  so,  when  its  striking  advantages  are  taken  into  consideration;  chief  among 
these  is  its  wide  margin  of  safety  in  the  hands  of  the  average  house  physician  alter 
complete  relaxation  is  achieved.  It  affords  complete  relaxation,  with  safety,  in  a 
group  of  cases  in  which  nitrous  oxid-oxygen  occasionally  fails — i.  c,  perineal  and 
pelvic  surgery  and  surgery  about  the  diaphragm.  Itself  a  stimulant  of  the  respira- 
tory and  vasopressor  centers,  it  is  least  often  followed  by  shock  when  properly  ad- 
ministered.    It  is  safest  in  arteriosclerotic  and  in  organic  heart  lesion-. 

When  preceded  by  nitrous  oxid,  ether  loses  its  chief  terror  to  the  patient  the 
relatively  long  period  of  discomfort  before  unconsciousness  is  attained.  It  is 
unsuited  in  all  cases  of  respiratory  and  renal  disease.  The  method  of  administra- 
tion of  choice  is  the  open  mask  drop  method,  preceded  in  the  modern  hospitals  in 
all  cases,  except  children,  by  nitrous  oxid  to  obtain  unconsciousness  quickly  and 
without  discomfort. 


370  OPERATION   OF   THE   HOSPITAL 

In  alcoholics  a  concentrated  vapor  is  attained  by  adding  folded  towels,  which 
are  removed  as  soon  as  may  be. 

Nitrous  Oxid-oxygen. — Nitrous  oxid-oxygen  has  rapidly  won  favor  in  some  of 
the  best  hospitals.  It  has  undoubted  advantages  over  ether  as  a  general  anesthetic, 
the  most  vital  of  these  being  its  transitory  effect  on  the  organism.  Nausea  and 
vomiting  are  practically  eliminated,  being  reduced  to  2  per  cent,  of  cases,  and 
careful  investigations  have  revealed  no  changes  in  the  blood  and  none  in  the  urine. 
It  is  much  more  desirable  in  all  respiratory  and  renal  diseases,  eliminating  almost 
entirely  the  dangers  of  uremia,  acute  bronchitis,  and  similar  sequelae. 

The  mortality  with  this  anesthetic  is  lowest  of  all  the  general  anesthesias — 
always  bearing  in  mind  these  facts:  that  it  is  contra-indicated  in  organic  heart 
disease  and  arteriosclerosis,  since  it  causes  an  increased  blood-pressure,  and  an 
overdose  of  nitrous  oxid  results  in  tonic  and  clonic  muscular  contractions,  which 
may  send  the  blood-pressure  to  a  disastrous  point,  and  it  is  the  most  difficult  of 
all  general  anesthetics  to  administer  because  of  the  extremely  narrow  margin  of 
safety  between  consciousness,  complete  unconsciousness,  and  an  overdose,  with 
symptoms  of  nitrous-oxid  poisoning.  Finally,  the  expense,  which  will  be  detailed 
later,  is  a  very  important  item  in  the  hospital  administration. 

Combined  Ether-nitrous-oxid-oxygen. — The  combined  method,  already  men- 
tioned, may  be  carried  to  a  point  of  high  efficiency,  and  some  of  the  best  anesthetists 
are  accustomed  to  nurse  dangerous  risks  along,  starting  with  nitrous  oxid-oxygen, 
switching  to  ether  if  the  patient  does  poorly  or  refuses  to  relax  properly,  and  then 
going  back  to  gas  again  as  soon  as  relaxation  is  attained;  occasionally  this  switch- 
ing will  be  made  two  or  three  times  in  the  course  of  an  operation,  and  a  patient 
believed  to  be  all  but  inoperable  will  be  worried  through  some  desperate  operation 
in  this  way  with  little  or  no  anesthetic  risk  and  insult. 

Gas  anesthesia  is  not  generally  well  understood,  and  it  may  safely  be  said  that 
many  of  the  mishaps  that  have  occurred  with  the  use  of  gas  were  due  to  inexpe- 
rience on  the  part  of  the  anesthetist. 

In  the  Michael  Reese  Hospital  continuous  nitrous  oxid-oxygen  is  used  in  about 
50  per  cent,  of  all  the  anesthesias,  and  it  is  used  in  any  procedure,  from  a  mere 
whiff  for  examination  in  the  anesthetizing  room  to  a  case  that  will  last  for  two  or 
three  hours,  as  witness  the  record  of  the  continuous  use  of  gas-oxygen  for  three  hours 
and  forty-five  minutes,  with  recovery,  in  a  case  of  universally  adherent  multilocular 
ovarian  cyst,  where  the  various  points  of  the  tumor  had  to  be  dissected  out  of  the 
abdominal  cavity,  and  its  use  continuously  for  an  hour  or  more  is  of  daily  occurrence. 

There  are  two  recognized  forms  of  apparatus  for  the  use  of  gas-oxygen.  One 
is  the  design  of  Dr.  Teter,  of  Cleveland;  an  excellent  apparatus,  if  somewhat  com- 
plicated; and  the  other  is  the  one  designed  in  the  Michael  Reese  Hospital,  a  much 
simpler  device.  This  apparatus  is  illustrated  in  the  sections  on  Equipment  of  the 
Operating-rooms. 

Within  the  past  year  a  new  design  of  gas-oxygen  apparatus  has  been  placed 
on  the  market;  the  cylinders  are  mounted  on  wheels,  and  the  oxygen  tank  holds 
750  gallons,  while  the  gas  tank  holds  1250  gallons.  The  chief  advantage  of  this 
larger  equipment  is  that  no  change  of  cylinders  need  occur  in  the  course  of  the 
operation  and  there  is  no  freezing  of  the  gas  to  delay  or  annoy  the  anesthetist; 
its  chief  disadvantage  is  a  somewhat  more  complicated  arrangement  of  valves, 
which,  unless  carefully  watched,  will  cause  a  waste  of  gas  by  leakage.  In  the 
Michael  Reese  Hospital  the  old  apparatus  is  set  upon  the  platform  of  the  new 
carriage,  and  we  have  then  the  advantage  of  the  larger  cylinders. 

Although  in  the  physical  laboratory,  under  controllable  conditions  of  pressure 


THE   SURGICAL   OPERATING-ROOMS  371 

and  temperature,  these  two  gases  can  be  mixed  on  a  percentage  basis,  in  the  opera- 
ting-room no  such  attempt  can  be  made,  the  quantity  of  oxygen  being  continually 
altered  to  suit  the  condition  of  the  patient.  The  mask  is  the  ordinary  mask  sup- 
plied by  the  S.  S.  White  Dental  Manufacturing  Co.  under  patents,  and  the  Teter 
Co.'s  gas  bags  are  the  best  that  are  made.  They  are  of  pure  rubber  and  protected 
by  a  net  that  prevents,  at  least  to  a  certain  degree,  undue  expansion.  The  usual 
procedure  in  gas  administration  is  to  administer  the  nitrous  oxid  pure  at  the  start, 
and  carry  it  to  a  point  where  the  patient  begins  to  show  asphyxiation,  as  expressed 
in  the  beginning  cyanosis  of  the  face.  Then  a  small  flow  of  oxygen  is  added, 
which  serves  to  clear  the  patient's  face  and  skin  and  yet  hold  him  unconscious  and 
relaxed.  This  administration  of  gas  and  oxygen  cannot  be  made  by  any  set  rule 
or  on  any  percentage  basis,  the  patient's  condition  being  the  only  guide. 

There  is  a  very  simple  form  of  apparatus,  made  by  most  of  the  gas  manufactur- 
ing concerns,  that  consists  of  a  standard  with  a  tank  of  gas  on  either  side  and  a  gas 
bag  suspended  from  another  point.  A  modification  of  this  same  apparatus  consists 
in  using  a  tank  of  gas  on  one  side  and  oxygen  on  the  other,  the  gases  both  going 
through  the  same  bag.  The  principle  of  this  bag  is  wrong,  of  course,  as  the  bag 
must  be  emptied  of  gas  before  an  unmixed  oxygen  can  be  had  for  the  patient's 
revival  if  things  do  not  go  right,  and  the  patient  might  die  long  before  the  bag  hail 
been  emptied  and  the  oxygen  brought  into  use. 

The  Johns  Hopkins  Hospital  has  designed  an  apparatus  employing  the  principle 
of  rebreathing,  by  which  the  nitrous  oxid  is  inhaled  and  exhaled  and  reinhaled  a 
number  of  times.  That  institution  claims  great  merit  for  the  apparatus,  but  others 
who  have  tried  it  very  carefully,  and  with  every  intent  to  succeed  with  its  use,  have 
been  unable  to  do  so.  It  is  knowm  that  exhaled  breath  contains,  besides  carbon 
dioxid,  definite  if  small  quantities  of  toxic  volatile  substances,  and  it  seems  to  those 
who  have  tried  this  rebreathing  method  that  there  is  a  profounder  poisoning  follow- 
ing it  than  with  the  direct  use  of  fresh  gas  all  the  time,  and  the  patients  seem  to  have 
taken  this  profound  poisoning  back  to  their  beds,  and  to  have  been  some  time 
recovering,  whereas  with  fresh  gas  and  without  its  re-use,  but  with  the  employment 
of  carefully  administered  oxygen,  the  patient,  even  after  a  long  operation  of  an 
hour  or  two,  wakes  up  almost  refreshed,  and  within  a  few  respirations  after  the  gas 
is  discontinued  and  pure  oxygen  substituted  the  patient  usually  gets  back  to  bed 
without  any  nausea  and  without  any  apparent  exhaustion,  and  there  seem  to  be 
no  ill  after-effects. 

There  is  at  present,  however,  thanks  to  the  illuminating  theories  on  acapnia 
and  shock,  as  advanced  by  Professor  Henderson,  of  Yale,  considerable  experimenting 
being  done  in  the  use  of  carbon  dioxid  during  anesthesia,  and  especially  in  the 
nitrous  oxid-oxygen  method. 

In  the  Michael  Reese  Hospital  this  newest  adjunct,  intended  to  serve  as  a  weapon 
against  shock,  is  employed  in  two  ways — first,  as  pure  carbon  dioxid  compressed 
and  available  at  will,  and,  secondly,  in  combination  with  oxygen  as  an  8  per  cent, 
admixture  of  carbon  dioxid,  these  combined  gases  being  used  in  the  oxygen  tanks 
instead  of  pure  oxygen.     This  whole  principle  is  yet  in  the  experimental  stage. 

Choice  of  Anesthetic—  With  most  patients  the  surgeon  himself  will  choose  liis 
anesthetic,  in  view  of  the  patient's  condition,  as  expressed  in  the  physical  examina- 
tion of  heart  ami  lungs  and  the  pathology  of  the  ease,  and  in  the  urine  as  indicative 
of  the  kidney  condition.  In  the  operating-rooms  of  the  better  hospitals  the  choice 
of  the  anesthetic  seems  to  be  a  routine  one.  based  on  these  findings,  and  the  choice 
is  usually  made  by  the  hospital  interns  along  lines  of  policy  established  by  the 
institution's  surgical  staff. 


372  OPERATION    OF   THE    HOSPITAL 

The  Cost  of  Anesthetics. — In  the  administration  of  ether  the  personal  equation 
is  a  very  important  factor.  Some  anesthetists  can  use  an  open  mask,  and  yet  keep 
a  patient  nicely  asleep  on  an  amount  of  ether  that  would  make  no  impression  on 
him  at  the  hands  of  another  anesthetist,  whose  method  would  result  in  the  evapo- 
ration outward  of  a  very  much  larger  proportion  of  the  anesthetic. 

There  is  much  to  be  said  about  the  cost  of  ether.  The  Squibb's  ether  contains 
a  small  percentage,  about  2  per  cent.,  of  alcohol,  and  its  evaporation  from  the 
mask  is  very  much  less  than  it  would  be  if  the  drug  were  pure. 

The  Malinckrodt  ether  has  about  the  same  quantity  of  alcohol,  and  experi- 
ments conducted  in  the  laboratory  of  the  Michael  Reese  Hospital  indicate  that 
under  identical  temperature  conditions  the  two  varieties,  when  exposed  in 
identical  calibrated  glass  receptacles  with  identical  evaporating  surfaces,  have 
the  same  rate  of  evaporation;  moreover,  the  quantity  administered  per  hour  per 
patient,  when  averaged  over  long  periods,  is  about  the  same.  The  cost  of  the 
Malinckrodt  ether  is  much  less  than  that  of  Squibb's  product.  Most  of  the  large 
institutions  of  the  country  use,  indifferently,  either  Squibb's  or  Malinckrodt's  ether, 
and  with  about,  the  same  results  apparently,  excepting  in  the  matter  of  cost,  which 
is  in  favor  of  the  Malinckrodt. 

The  cost  of  gas-oxygen  for  anesthetic  purposes  is  a  very  considerable  item, 
either  in  the  running  expenses  of  the  operating  department  or  from  the  standpoint 
of  the  patient,  if  there  is  a  charge  made  for  the  gas.  Nitrous  oxid  costs  from  $1.25 
to  $2  for  a  100-gallon  tank,  according  to  the  amount  purchased  by  the  institution, 
and  oxygen  in  the  same  compression  tanks  costs  about  the  same  for  40  gallons. 
A  single  tank  of  nitrous  oxid  of  100  gallons  will  last  an  average  of  about  25  minutes— 
that  is,  it  will  require  two  to  two  and  one-half  tanks  to  do  an  operation  extend- 
ing over  one  hour.  Some  patients  require  much  less  than  this,  while  other  patients, 
especially  alcoholics,  and  those  that  have  been  accustomed  to  narcotic  drugs, 
will  require  very  much  more,  and  the  amount  used  will  also  depend  a  good  deal 
on  whether  the  gas  must  be  used  without  any  considerable  mixture  of  oxygen, 
or  whether  a  good  deal  of  oxygen  has  to  be  used  from  time  to  time  during  the 
operation  to  avoid  cyanosis.  Taken  on  the  average,  from  200  to  250  gallons  of 
gas  and  40  to  50  gallons  of  oxygen  per  hour  will  be  used.  If  the  nitrous  oxid 
is  used  rapidly  during  the  anesthesia  the  tanks  are  likely  to  freeze  at  the  valve, 
and  must  then  be  shut  off  until  they  thaw  out  again,  and,  where  careless  people 
handle  the  gas,  a  good  deal  of  it  is  lost,  because  they  neglect  to  use  the  balance 
of  it  after  the  valve  thaws  out,  which  occurs  in  a  few  minutes. 

Although  we  have  discussed,  under  the  section  on  Records  of  Patients,  the 
necessity  of  making  urinalyses  and  of  obtaining  a  permit  for  the  operation,  we  may 
be  pardoned  for  very  briefly  mentioning  these  two  items  of  procedure  again,  especi- 
ally the  routine  practice  of  never  giving  a  general  anesthetic  to  a  patient  without 
the  report  of  the  urinalysis  being  present  in  the  operating-room  for  purposes  of 
observation.  It  cannot  be  too  strongly  insisted  upon.  Where  this  is  not  practised 
many  a  patient  has  been  put  to  sleep  with  ether  whose  urine  examination  showed  a 
kidney  condition  that  would  absolutely  prohibit  that  form  of  anesthesia,  and,  as 
a  rule,  the  urinalysis  will  have  a  very  large  weight  in  the  choice  of  the  anesthetic 
to  be  used  and  the  after-conduct  of  the  anesthesia  itself. 


the  surgical  operating-rooms  373 

Rules  for  the  Administration  of  Anesthetics 
General  Remarks. 

While  the  operating  surgeon  cannot  waive  his  responsibility  for  the  proper 
conduct  of  the  anesthetic,  it  sin  mid  lie  the  duty  of  the  hospital  administration  to 
establish  and  carry  out  a  routine,  acceptable  to  the  surgical  staff,  that  will  ensure 
a  high  order  of  service  and  reduce  the  danger  of  accident  to  the  lowest  possible 
point.  We  have  discussed  elsewhere  the  preliminary  permit  for  the  operation  and 
the  establishment  of  the  patient's  condition,  as  expressed  in  the  urinalysis  and 
blood-pressure,  and  of  the  duty  of  the  operator  or  his  medical  associates  to  select 
the  anesthetic  to  be  given  in  all  debatable  cases.  However,  if  rigid  rules  are 
enforced,  based  upon  a  broad  experience,  even  these  duties  become  negligible  in 
a  properly  conducted  hospital. 

We  have  discussed  elsewhere  also  the  personnel  of  the  anesthetic  service;  let 
us  add  only  the  suggestion,  that  oftentimes  a  very  simple  surgical  procedure  may 
take  on  extremely  grave  complications,  chargeable  directly  to  the  anesthetic,  and 
the  most  critical  operations  may  go  smoothly  and  terminate  happily  if  the  anes- 
thetic is  administered  in  a  masterful  and  workmanlike  manner. 

The  Anesthetist. 

All  human  beings  have  their  "off"  days,  and  the  giving  of  an  anesthetic  is  a 
trying  ordeal  at  best;  consequently,  no  person  should  officiate  unless  he  is  men- 
tally placid  and  calm  and  physically  sound. 

He  should  be  personally  clean,  and  not  have  come  from  the  postmortem  room, 
from  a  pus  dressing,  or  from  attendance  on  communicable  disease,  and  especi- 
ally erysipelas. 

He  should  be  free  from  ear,  nose,  throat,  or  eye  infections. 

He  should  be  perfectly  familiar  with  the  operating-table  and  all  its  movements 
and  possibilities. 

He  should  have  available  for  immediate  use  and  understand  thoroughly  the 
emergency  set  for  subcutaneous  or  intravenous  administration  of  salt  solution 
(Locke's  formula). 

Preparation  of  the  Apparatus. 

All  anesthetic  apparatus  should  be  ready  before  the  time  set  for  operation. 
No  anesthetic  may  be  started  until  there  is  an  ordinary  mouth-gag,  a  Heister  gag, 
tongue  forceps,  throat  swabs,  gauze,  towels,  fan,  and  pus  basin  at  hand. 

An  ether  can  should  be  opened  and  a  double-grooved  cork  with  cotton  wick 
should  be  prepared.  Only  the  drop  method  on  an  open  mask  is  to  be  employed, 
except  on  the  special  order  of  the  operating  surgeon. 

N20  Oj  apparatus  must  be  tested  beforehand.  The  face  mask  must  be  clean 
and  the  valves  working  freely.  All  four  cylinders  must  contain  some  gas  or  oxy- 
gen.    New  cylinders  with  tried  valves  must  be  available. 

The  method  of  cleaning  the  masks  consists  in  boiling  for  the  ether  masks,  and 
in  soap  and  water  cleansing,  followed  by  ten  minutes'  immersion  in  5  per  cent, 
carbolic  solution,  for  the  gas  masks  with  rinsing  in  sterile  water. 

The  hypodermic  tray  should  contain  a  syringe  loaded  with  strychnin,  gr.  .,'„ 
(0.0021,  and  another  with  Til  xxv  (1.7)  of  camphor  in  oil,  and  the  following  prepara- 
tions ready  for  immediate  hypodermic  use: 

Caffein.  Adrenalin.  Digalen. 

Nitroglycerin.  Camphor  in  ether.  Morphin. 


374  OPERATION   OF   THE    HOSPITAL 

Preparation  of  the  Patient 

The  blood-pressure  must  be  known  in  all  cases  scheduled  for  operation.  Urin- 
alysis must  be  recorded,  and  operating  permit  signed  by  the  patient  if  an  adult, 
by  the  legal  guardian  if  a  minor  or  mentally  incompetent,  or  by  the  hospital  author- 
ities if  an  emergency  case  be  in  profound  shock  or  unconscious  from  hemorrhage 
before  bringing  the  patient  to  the  preparatory  room. 

Before  starting  the  anesthetic,  be  sure: 

(1)  That  the  patient's  mouth  is  empty,  i.  e.,  artificial  teeth  removed. 

(2)  That  there  is  no  constriction  about  the  neck. 

(3)  That  the  position  is  the  desired  one  on   the  appropriate  table — the 

patient  should  be  as  far  toward  the  foot  of  the  table  as  possible. 

(4)  That  arms  and  legs  are  properly  secured  and  no  straining  or  cramping 

of  limbs. 

(5)  That  the  head  pillow  is  out,  or  is  removed  shortly  after  starting  the 

anesthetic. 

Administration 

A.  Choice  of  anesthetic. 

The  routine  anesthetic  for  adults  is  N20,  followed  by  ether;  for  children  straight 
ether.  Variations  from  this  will  be  under  instructions  from  the  operator  or  the  staff 
anesthetist. 

Ether  is  contra-indicated  in: 

(1)  Infections  of  the  respiratory  tract. 

(2)  Nephritis. 

(3)  Brain  surgery. 

N,0-02  (continuous  gas  anesthesia  and  preliminary  gas  anesthesia)  is  contra- 
indicated  in  cases  with  the  following : 

(1)  Blood-pressure  above  165  mm. 

(2)  Myocarditis  and  serious  valvular  lesions. 

(3)  High-grade  arteriosclerosis. 

B.  Guides  to  depth  of  anesthesia  and  condition  of  the  patient: 

(1)  Respiration;  somewhat  quickened,   deep  and  regular.     Judge  by  the 

sound  and  by  watching  chest  or  abdomen.     Noisy,  stertorous  breath- 
ing usually  means  the  tongue  has  fallen  backward. 

(2)  The  pulse;  note  the  rate,  volume,  and  rhythm:  it  should  be  full  and 

somewhat  quickened. 

(3)  Color:  This  may  be  slightly  cyanosed  in  continuous  gas,  but  in  no  other 

anesthesia. 

(4)  Muscular  relaxation  and  reflexes. 

(5)  The  pupils:  These  should  be  small  and  sharply  reacting;  when  testing, 

hold  the  lid  closed  an  instant,  then  open  toward  the  light.      Never 
touch  the  cornea.     Morphin  renders  the  pupil  test  useless. 

C.  Details  of  administration: 

Never  be  left  alone  with  a  patient  after  starting  the  anesthetic. 

Take  the  patient  to  the  operating-room  as  soon  as  possible  after  unconscious- 
ness (not  complete  surgical  anesthesia)  supervenes  and  reach  surgical  anesthesia 
in  the  operating-room. 

The  anesthetist  must  concentrate  his  attention  on  the  anesthetic.  The  opera- 
tor wishes  to  rely  on  the  anesthetist,  but  cannot  be  expected  to  do  so  if  he  finds  him 
inspecting  the  field  of  operation  instead  of  watching  the  patient. 


THE   SURGICAL   OPERATING-ROOMS  375 

Note  the  time  of  starting  and  finishing  the  anesthesia;  keep  a  written  pulse 
record  every  ten  minutes  on  tablets  provided  for  that  purpose.  (This  need  not 
interfere  with  constant  attention  to  the  pulse.) 

Do  not  use  tongue  forceps  nor  ordinary  mouth  nor  Heister  gag  unless  it  seems 
imperative.  Extension  of  the  head  and  protrusion  of  the  lower  jaw  held  under 
the  symphysis  suffices  nearly  always  to  open  the  respiratory  tract.  Avoid  throat 
swabbing,  which  rarely  reaches  the  mucus  that  is  causing  the  noisy  breathing  and 
usually  excites  further  mucus  production.  Avoid  prolonged  pressure  at  the  angles 
of  the  jaw — it  always  causes  soreness  for  several  days,  and  occasionally  a  traumatic 
parotitis.  In  holding  the  jaw  under  the  symphysis  keep  hands  and  fingers  off  the 
trachea  and  vessels  of  the  neck. 

Protect  the  eyes,  and  if  ether  does  reach  the  conjunctiva  instil  a  drop  of  castor 
oil  at  once. 

Always  remove  the  anesthetic  during  beginning  dilation  of  the  rectal  sphincter. 

During  vomiting  never  interfere  with  tongue  nor  jaw.  Turn  the  head  and 
shoulders  sideways,  wipe  out  ejecta  to  avoid  aspiration,  and  then  crowd  the  anes- 
thetic. 

The  anesthetic  may  be  crowded: 

(1)  Just  before  and  during  the  stage  of  excitement. 

(2)  Just  before  vomiting,  as  evidenced  by  swallowing  motions  of  the  throat 

and  shallow,  rapid  breathing. 

(3)  Just  after  vomiting. 

(4)  At  the  operator's  request,  and  if  the  patient's  condition  is  good. 

(5)  When  hypersensitive  areas  are  being  handled,  as  the  diaphragm,  the 
Douglas,  and  the  perineum. 

Avoid  supersaturation  of  the  mask — the  excess  ether  is  wasted,  and  may 
drip  into  the  patient's  mouth  and  throat  and  thus  cause  further  mucus  pro- 
duction. 

D.  Economy  and  statistics. 

Two  hundred  and  fifty  grams  ether  cans  contain  350  c.c.  Measure  by  volume 
the  quantity  used  at  each  operation;  the  first  350  c.c.  should  last  from  one  and 
one-fourth  to  one  and  one-half  hours,  except  for  alcoholics  and  patients  accustomed 
to  narcotics  and  stimulants.  N20  cylinders  contain  100  gallons.  For  continuous 
anesthesia  the  average  is  200  to  250  gallons  N20  per  hour. 

Do  not  remove  N20  nor  02  cylinders  from  the  apparatus  until  empty.  It  is 
not  necessary  to  start  each  operation  with  full  cylinders.  Some  one  must  use  up 
those  partly  empty. 

E.  Danger  signals: 
In  ether  anesthesia: 

(1)  Respirations  shallow,  gasping,  or  obstructed. 

(2)  Pulse-rate  rising,  volume  decreasing  (more  than  the  length  of  operation 

or  loss  of  blood  warrants). 

(3)  Mucus  accumulating  in  throat. 

(4)  Cyanosis  beginning. 

(5)  Pupils  dilating  and  reacting  sluggishly  or  not  at  all. 
In  NjO-Oj  anesthesia: 

(1)  Cyanosis. 

(2)  Muscular  twitching — seen  first  about  the  eyelids  and  extremities. 

(3)  Eyeballs  turning  upward — pupils  dilating. 

(4)  Pulse-rate  decreasing. 

(5)  Respirations  slowing — stertorous. 


376  OPERATION    OF   THE   HOSPITAL 

F.  Efforts  at  resuscitation: 

If  the  patient  stops  breathing: 

(1)  Remove  the  anesthetic. 

(2)  Artificial  respirations,  15  to  20  per  minute,  combined  with  famiing  or 

the  use  of  oxygen.  The  upward  arm  motion  or  expansion  of  the  chest 
must  be  simultaneous  with  outward  traction  on  the  tongue. 

(3)  Make  sure  of  an  open  and  unobstructed  respiratory  tract. 

(4)  Rhythmic  tongue  traction  associated  with  artificial  respirations. 

(5)  Lower  the  head  and  chest  to  stimulate  the  medullary  centers.     (In 

early  chloroform  cardiac  paralysis,  with  engorgement  of  the  heart  and 
thoracic  vessels,  raise  the  head  and  chest  for  half  a  minute  to  help 
empty  by  gravity  the  overburdened  heart  and  vessels,  and  then  place 
body  flat.) 

(6)  Heart  massage — 120  per  minute.     In  the  absence  of  a  pulse,  successful 

heart  massage  makes  a  palpable  pulse  in  the  carotid  arteries. 

(7)  Drugs,  hypodermic — strychnin,  gr.  ^c,  repeated;  camphor  in  oil,  one  or 

two  barrels  (fflxxv  each);  digalen,Ttlx,  repeated;  caffein,  gr.  j. 

(8)  Stretch  anal  sphincter. 

G.  Responsibility: 

Do  not  assume  unnecessary  responsibility  when  acting  alone.  If  in  doubt 
stop  the  anesthetic,  and  give  air  or  oxygen  until  your  doubt  is  removed.  A  struggling 
patient  is  better  than  a  death  from  anesthesia.  If  the  general  condition  of  the 
patient  is  disquieting,  announce  the  fact  or  facts  on  which  your  judgment  is  based 
to  the  operator. 

Note. — These  rules  are  in  use  in  the  Michael  Reese  Hospital,  and  were  prepared 
by  Dr.  Joseph  L.  Baer,  of  the  anesthetic  staff  of  the  institution. 

MINOR  SURGICAL  TECHNIC  AND  APPARATUS 

There  are  a  few  minor  surgical  operations  that  are  usually  done  with  the  patient 
lying  in  bed.  The  operations  are  often  left  to  the  house  medical  staff  and  the 
nurse.  It  may  be  helpful,  therefore,  to  emphasize  some  of  the  fundamentals  of 
technic  and  list  the  apparatus  and  material  required  of  the  nurses. 

Spinal  Puncture. — Instruments. — Needle,  2\  inches  long;  syringe  for  injection 
of  serum  (Quincke  trochar  and  cannula) ;  sterile  tubes. 

Site  of  puncture  is  between  the  fourth  and  fifth  or  third  and  fourth  lumbar 
vertebra,  and  an  easy  method  of  finding  this  is  by  going  in  parallel  with  the  crest 
of  the  ilium.  In  children  the  needle  is  inserted  directly  in  the  midline,  and  in  adults 
the  needle  is  generally  inserted  about  \  inch  the  other  side  of  the  midline  and 
pointed  slightly  inward  and  upward.  The  patient's  skin,  the  operator's  hands, 
and  the  field  of  operation  must  be  sterilized  as  for  a  surgical  operation. 

Position  of  Patient. — The  patient  is  preferably  lying  in  bed  on  one  side,  with  head 
flexed  on  the  chest,  knees  flexed  on  the  thigh,  and  the  thigh  flexed  as  close  to  the 
body  as  possible,  making  the  back  as  convex  as  possible,  so  as  to  separate  the  ver- 
tebra. Some  prefer  doing  lumbar  puncture  with  the  patient  sitting  up,  but  in  a 
reclining  position.  After  the  procedure  the  field  of  operation  is  best  dressed  by  a 
piece  of  sterile  cotton  or  gauze  covered  with  a  strip  of  adhesive  plaster. 

The  needle  is  inserted  as  directed,  and  when  it  enters  the  spinal  canal  the  fluid 
will  immediately  flow.  It  is  never  necessary  to  exert  suction  on  the  needle  to  with- 
draw fluid.  A  "dry  tap"  generally  means  that  the  needle  has  not  entered  the  canal, 
but  it  may  indicate  an  absence  of  fluid  due  to  inflammatory  involvement  of  the 
cerebrospinal  meninges,  which  has  closed  the  foramen  of  Magendie. 


THE   SURGICAL   OPERATING-ROOMS  377 

Venesection. —  Instrument*. — Two  pair  artery  snaps;  2  pair  tissue  forceps; 
1  pair  stitch  scissors;  1  pair  small  curved  scissors;  2  small  knives;  1  probe-pointed 
grooved  director;  1  hook;  1  probe-pointed  aspirating  needle;  2  aneurysm  needles. 

In  test-tubes,  add— 2  aspirating  needles;  horsehair  and  needles;  silkworm  and 
needles;  white  silk  and  needles:  catgut  No.  0  and  needles;  pipets. 

Also  add  to  tray — sterile  towels;  sterile  brushes;  sterile  cotton;  2  medicine- 
glasses;  camel's  hair-brushes;  bandages,  all  sizes. 

The  patient  is  lying  in  bed,  with  arm  extended  on  the  side  of  the  bed.  When 
time  permits  it  is  best  to  dissect  down  on  the  vein.  The  first  procedure  is  to 
compress  the  arm  above  the  elbow  until  the  veins  in  the  elbow  stand  out  promi- 
nently. The  skin  incision  can  best  be  made  by  pulling  the  skin  slightly  aside  from 
the  vein  and  cutting  to  the  level  of  the  vein  in  one  stroke.  This  avoids  the  danger 
of  cutting  the  vein  in  the  preliminary  skin  incision.  The  vein  is  then  dissected 
free  from  the  surrounding  tissue  and  a  ligature  placed  ready  to  tie.  A  sharp  scis- 
sors is  used  to  make  a  "V"  incision  with  the  apex  pointing  distaUy.  When  suffi- 
cient blood  has  been  obtained  the  ligature  is  tied  distal  to  the  incision  and  the 
skin  sewed  up  with  two  or  three  silk  stitches.  By  some  it  is  preferred  to  lay  the 
stitches  in  the  skin  before  making  the  incision  in  the  vein  and  simply  stop  the  ven- 
ous flow  by  pressure.  In  case  of  emergency  a  knife-cut  through  the  skin  and  across 
the  surface  of  the  vein  will  perform  the  duty. 

Direct  Transfusion. — For  direct  transfusion  of  salt  solution  or  of  drugs  into  the 
circulation  the  technic  of  exposing  the  vein,  as  above  outlined,  is  employed.  How- 
ever, when  the  vein  is  exposed  and  dissected  free  two  ligatures  are  laid,  about  1 
inch  or  more  apart.  The  lower  distal  one  is  tied  before  the  incision  is  made,  there- 
by stopping  the  flow  of  blood.  A  small  cannula  is  inserted  through  or  cut  into  the 
vein  and  tied  with  the  proximal  ligature.  In  the  meantime,  the  cannula  must  be 
connected  with  the  solution  for  injection  and  all  air-bubbles  allowed  to  run  out 
before  the  cannula  is  inserted  in  the  vein.  The  constriction  on  the  arm  is  then 
removed,  and  the  fluid,  always  kept  at  body  temperature,  is  allowed  to  run  slowly 
into  the  circulation — fifteen  minutes  for  100  c.c.  is  the  time  generally  used.  After 
sufficient  fluid  is  allowed  the  cannula  is  withdrawn,  the  proximal  ligature  tied,  and 
the  skin  sewed  and  dressed  as  above  described. 

Subcutaneous  Transfusion. — For  infusion  of  salt  solution,  or  of  Locke  or 
Ringer  solution,  an  outfit  containing  the  necessary  apparatus  should  always  be  on 
hand.  The  sites  generally  selected  for  infusion  are  under  the  breast  or  the  exter- 
nal aspect  of  the  thigh.  The  needle  is  generally  about  2  to  2h  inches  long  and  of 
not  very  large  caliber.  The  field  of  operation  is  sterilized  as  for  a  surgical  opera- 
tion, and  the  needle,  connected  with  the  fluid  which  is  suspended  at  the  proper 
height,  is  inserted  rather  deeply  in  the  subcutaneous  tissue.  The  fluid  is  allowed 
to  flow  slowly,  and  light  massage  is  made  over  the  area  after  the  fluid  enters  the 
tissue. 

Paracentesis.— Paracentesis  thoracis  may  be  divided  into  two  parts:  one  explor- 
atory, when  the  nature  of  the  fluid  is  unknown,  and.  second,  for  the  aspiration  of 
a  known  non-purulent  fluid.  In  cither  case,  the  site  of  the  puncture  depends  on 
physical  signs  of  localization  of  the  fluid.  After  sterilization  of  the  field  the  needle, 
attached  to  a  good  working  syringe,  is  applied  along  the  upper  borders  of  the  rib 
and  gently  pushed  straight  toward  the  pleura.  When  the  pleura  is  reached  there 
is  a  perceptible  change  in  the  resistance  to  the  needle,  which  is  then  shoved  a  little 
further  in  in  order  to  pierce  the  pleura.  Suction  is  then  made  by  means  of  the  ->  ringe 
and  the  nature  of  the  fluid  ascertained,  [f  it  is  desired  t>>  evacuate  a  large  amount 
of  fluid  the  needle  is  then  connected  with  an  aspiration  outfit,  by  which  negative 


378  OPERATION    OF   THE    HOSPITAL 

pressure  can  be  produced  in  the  large  receiving  bottle.  Negative  pressure  may  be 
made  either  by  a  suction  pump  attached  to  the  other  end  of  a  bottle  which  has 
valves,  or  in  the  absence  of  such  an  apparatus,  a  convenient  vacuum  can  be  obtained 
by  burning  alcohol  in  a  bottle  and  immediately  stoppering  it. 

In  paracentesis  abdominus  a  trochar  and  cannula  is  used  instead  of  a  needle, 
and  the  skin  is  generally  nicked  with  a  knife  before  insertion  of  the  trochar.  The 
incision  of  choice  is  about  midway  between  the  symphysis  and  umbilicus,  after  the 
operator  has  made  certain  that  the  urinary  bladder  is  empty.  The  patient  is 
best  sitting  in  bed,  propped  up  on  pillows  if  necessary.  In  paracentesis  abdomi- 
nus there  is  some  danger  of  shock,  and  it  is  always  wise  in  all  punctures  to  have  stim- 
ulants ready  for  immediate  use. 

Wet  Dressing  Box. — Green  soap;  sterile  gauze;  sterile  cotton;  sterile  towels; 
scrub-brushes  (sterile);  sterile  camel's  hair-brushes;  toothpick  swabs;  bandages 
of  various  sizes;  alcohol;  ether;  tincture  of  iodin;  collodion;  oiled  muslin;  rubber 
tissue;  safety-pins;  lap  binder. 

Preparation  of  Bodies  for  the  Morgue. — Contents  of  Morgue  Box. — Five  pounds 
oakum;  non-absorbent  cotton;  straight  pins;  stick;  morgue  sheet;  safety-pins; 
bandages,  2-  or  3-inch. 

The  Adult  Body. — The  body  must  be  bathed  all  over  with  soap  and  water,  the 
finger-  and  toe-nails  cleaned,  the  hair  combed  and  braided,  and  the  ends  tied  tightly. 
The  rectum  is  packed  with  oakum,  and,  if  the  body  be  that  of  a  female,  the  vagina 
will  be  packed,  and  a  large  pad  or  diaper  will  be  adjusted  to  cover  rectum  and 
vagina.  The  throat  and  nostrils  must  be  packed  with  oakum  and  the  eyes  band- 
aged, with  a  wad  of  cotton  underneath  the  bandage  to  press  on  the  lids  sufficiently 
to  keep  them  closed.  If  there  is  a  wound  following  an  operation  the  dressings 
must  be  removed  and  clean  dressings  put  on,  with  a  sufficient  amount  of  packing 
to  prevent  oozing.  The  dressings  may  be  fastened  with  adhesive  plaster  instead 
of  a  regular  binder.  The  ankles  are  tied  together,  and  also  the  legs  below  the  knees. 
The  arms  are  folded  over  the  chest,  and  the  wrists  are  tied  lightly  together  with  a 
broad  bandage,  so  that  the  skin  underneath  will  not  be  discolored  when  the  band- 
age is  removed  previous  to  burial.  There  need  be  no  clothing  on  the  body  other 
than  the  morgue  sheet,  which  must  be  invariably  pinned  in  front  throughout  its 
whole  length,  the  superfluous  material  being  tucked  in  as  a  pad,  especially  over  the 
face.  The  sheet  must  be  pinned  on  in  such  a  manner  that  the  face  can  be  quickly 
exposed. 

The  death  report,  fully  made  out,  with  name  and  all  necessary  data,  must  be 
pinned  over  the  face  to  the  morgue  sheet.  All  jewelry  must  be  removed  from 
the  body,  unless  otherwise  specifically  directed,  and  turned  over  to  the  head  nurse. 
The  body  must  be  removed  to  the  morgue  immediately  after  the  preparations  are 
completed  unless  there  are  specific  orders  to  the  contrary.  The  head  nurse  of  the 
floor  must  as  expeditiously  as  possible  thereafter  send  the  patient's  clothing  and 
all  other  belongings  to  the  office,  and  take  a  receipt  in  detail  therefor. 

The  Child. — Children  beyond  the  infant  age  will  be  treated  as  adults.  The 
infant  must  be  washed,  and  a  diaper  of  gauze  and  cotton  put  on.  The  body  must 
then  be  wrapped  in  a  thin  pad  of  cotton  and  gauze,  and  over  this  the  morgue  sheet, 
as  in  the  case  of  adults. 

Premature  infants  and  still-boms  must  be  treated  exactly  as  other  infants,  and 
must  under  no  circumstances  be  sent  to  the  laboratory  of  pathology  except  on 
specific  order  of  the  superintendent  of  the  hospital. 


DEPARTMENT  OF  PATHOLOGY 

In  this  era  of  pathology,  bacteriology,  serum,  and  vaccine  therapy  the  depart- 
ment devoted  to  this  work  in  the  modern  hospital  may  be  said  to  have  four  func- 
tions: First,  as  an  aid  to  diagnosis;  second,  as  a  part  of  the  treatment  of  disease; 
third,  educational  as  contributing  to  the  literature  of  medicine;  and,  fourth,  experi- 
mental medicine  in  the  employment  of  animals  for  testing  and  proving  theories 
that  have  for  their  ultimate  object  the  cure  of  disease. 

It  might  have  been  said  only  a  few  years  ago  that  the  chief  function  of  the 
department  of  pathology  was  as  an  aid  to  diagnosis;  that  is  not  true  to-day,  and 
its  office  in  the  treatment  of  the  disease  after  its  nature  has  been  definitely  estab- 
lished is  quite  as  important,  as,  for  instance,  iii  vaccine  and  serum  therapy. 

Almost  the  whole  literature  of  modern  medicine  is  made  up  of  the  records  of 
patients  on  the  wards  of  the  hospital,  and  a  very  valuable  part  of  these  records  is 
that  which  contains  the  work  of  the  department  of  pathology.  In  the  light  of 
to-day's  progress  in  medicine  and  its  various  branches  there  could  be  no  literature 
worthy  the  name  that  did  not  contemplate  urinology,  bacteriology,  surgical,  and 
postmortem  pathology. 

The  final  function,  and  perhaps  eventually  the  most  important  of  all,  concerns 
research  into  the  cause  and  character  of  disease  with  a  view  to  its  cure,  and  this 
research  function  of  hospital  pathology  is  a  question  of  the  ambitions  of  individuals 
on  medical  staffs,  of  the  caliber  of  men,  of  equipment,  and  of  material  in  the  form 
of  patients  with  which  to  operate. 

Hospital  pathology  as  a  well-rounded  branch  of  administration,  with  definite 
clinical  aims  and  clear-cut  technic,  is  rather  new,  and  clinicians  themselves  are  just 
learning  its  resources  and  limitations.  Its  functions  are  not  only  to  aid  the  men 
in  the  diagnosis  and  treatment  of  their  cases,  but  to  inspire  them  with  a  spirit  of 
investigation,  and  to  open  up  to  them  speculative  fields  for  clinical  study  with  its  aid. 

We  need  not  look  for  very  much  inspiration  in  the  laboratory  from  the  older 
medical  men,  because  they  are  not  quite  sure  themselves,  and  they  do  not  always 
know  just  how  far  the  laboratory  can  go  to  help  them,  therefore  the  directors  of 
the  laboratory  must  keep  in  touch  with  staff  members  in  the  medical  profession, 
and  must  act  as  a  sort  of  binding  link  between  the  laboratory  and  the  bedside. 

It  will  not  be  necessary  or  profitable  for  us  to  go  into  the  question  of  the  extent 
to  which  a  laboratory  department  can  be  carried  in  the  hospital,  but  rather  we  might 
discuss  very  briefly  some  fundamental  principles  of  laboratory  operation  as  applied 
to  hospital  practice  in  conjunction  with  bedside  work. 

Who  Shall  Do  the  Work? — The  most  vital  problem  concerned  in  the  organiza- 
tion and  operation  of  a  department  of  hospital  pathology  concerns  the  personnel — 
who  shall  do  the  work  of  the  institution?  The  problem  is  not  a  very  difficult  one, 
and  settles  itself  in  the  large,  richly  endowed  institutions  that  can  afford  an  elabo- 
rate organization;  and,  as  a  rule,  in  such  institutions,  which  are  almost  always 
connected  with  a  medical  school,  the  routine  work  will  be  done  by  senior  students 
under  the  direction  of  teachers  in  the  school.  The  urines  can  be  done  by  senior 
students  who  have  passed  a  period  of  apprenticeship,  and  who  are  always  under 
the  eye  of  a  trained  analyst.     Certain  of  the  baeteriologic  work,  including  the 


380  OPERATION    OF    THE    HOSPITAL 

staining,  can  also  be  done  by  senior  students,  but  very  much  of  this  class  of  labora- 
tory work  is  valuable  from  its  educational  side  only,  and  very  much  more  largely 
concerns  the  workers  than  the  patients  involved. 

Where  the  chief  function  of  the  laboratory  concerns  the  patient,  and  where 
that  department  is  maintained  as  an  aid  to  attending  physicians  in  practice  in  the 
institution,  medical  students  are  not  quite  reliable  if  left  too  much  to  themselves. 
The  institution  that  has  for  its  prime  and  only  function  the  care  of  patients  has  no 
medical  school  connection,  and  only  in  very  rare  instances  will  such  an  institution 
be  properly  endowed  to  maintain  a  large  pathologic  force.  Not  so  very  long  ago 
it  was  the  custom  to  charge  patients  for  laboratory  examinations,  and  it  is  the 
custom  still  in  some  places,  but  the  custom  is  becoming  obsolete,  and  it  is  coming 
to  be  a  common  view  that  the  doctor  is  entitled  to  all  the  aid  the  institution  can 
give  him  for  the  diagnosis  and  treatment  of  his  case,  and  urine  work,  bacteriology, 
and  pathology  are  coming  to  be  regarded  quite  as  essentially  a  part  of  the  routine 
of  the  hospital  as  the  dietary  or  good  nursing.  This  innovation  of  providing  labor- 
atory work  without  a  special  charge  against  patients  is  throwing  the  burden  of  a 
large  expense  on  the  institutions  which  most  of  them  cannot  afford.  But  the  whole 
question  is  one  of  education  on  the  part  of  the  physicians  who  bring  their  patients 
for  treatment  to  the  hospital,  and  physicians  are  now  becoming  so  well  educated 
in  the  laboratory  side  of  their  profession  that  they  know  what  good  laboratory  work 
means,  and  they  are  quite  able  to  separate  the  honor  work  and  efficient  service 
from  all  too  common  guess-work  practice.  After  all,  patients  go  to  the  hospital  in 
which  their  medical  advisor  has  confidence,  and  the  day  is  not  far  distant  when  the 
semiprivate  hospital  will  be  equipped  to  fix  a  flat  rate  room  charge  for  all  its  pay 
patients,  with  the  understanding  that  the  single  charge  includes  everything  the 
patient  will  need,  including  laboratory  work.  The  room  charge  in  such  a  case  will 
be  higher,  of  course,  but  the  patient's  bill  will  be  smaller  in  the  end,  and  the  doctor 
and  his  patient  will  get  very  much  more  for  their  money. 

This  brief  diversion  was  made  necessary  to  emphasize  the  point  that  hospital 
laboratory  work  cannot  be  done  in  a  competent  and  efficient  manner  by  students 
undirected  or  by  any  one  not  specially  trained. 

Necessarily  there  must  be  trained  experts  in  any  department  of  pathology  that 
will  be  entitled  to  respect.  If  the  institution  is  a  small  one,  one  man  with  an  all- 
round  training  will  perhaps  give  a  mediocre  satisfaction  in  the  organization  of  the 
department  and  in  the  checking  up  of  the  routine  work  undertaken  by  the  institu- 
tion in  urines,  bacteriology,  and  surgical  pathology. 

Where  the  work  is  more  varied  and  larger  in  quantity,  there  ought  to  be,  beside 
the  director,  one  other  trained  man,  preferably  one  skilled  in  bacteriology  and  work 
upon  the  blood,  who  can  also  do  the  Wassermann,  Widal,  and  such  other  scientific 
tests.  Good  interns  can  usually  be  intrusted  to  carry  out  the  technic  of  spinal 
puncture,  the  injection  of  antimeningitis  serum,  the  antitoxins,  and  the  various 
vaccines  on  the  wards.  A  conscientious  woman,  who  has  had  a  medical  train- 
ing, oftentimes  gives  the  highest  order  of  satisfaction  in  doing  the  Wassermann 
tests,  vaccines,  etc.,  but  the  same  person,  however  well  trained  she  may  be  and 
however  well  informed,  will  hardly  be  satisfactory  in  carrying  out  the  Avork  on 
the  floors  of  the  hospital,  for  the  same  reason  that  women  are  not,  as  a  rule, 
good  surgeons. 

In  a  good  many  institutions  the  interns  do  most  of  the  laboratory  work.  Work 
done  by  these  young  men  without  expert  direction  is  usually  a  fraud  on  the  physi- 
cian, who  is  looking  to  the  institution  for  conscientious  help,  and  a  fraud  on  the 
patient,  because  it  is  not  expert  work. 


DEPARTMENT  OF  PATHOLOGY  381 

There  is  a  way,  however,  to  employ  the  services  of  these  young  men  most 
adequately  and  efficiently.  There  is  no  medical  school  in  the  country,  with  pos- 
sibly two  or  three  exceptions,  that  gives  a  sufficient  practical  training  to  its  slu- 
dents  to  enable  them  to  do  the  hospital  laboratory  work  after  they  are  graduated 
without  the  direction  of  an  expert.  In  some  institutions,  however,  and  this  seems 
to  be  a  rather  coming  practice,  the  interns  immediately  upon  their  admission  to 
the  hospital  are  sent  to  the  laboratory,  and  there  given  practical  work  for  a  few 
weeks  in  urines  and  blood  work.  If  the  young  men  have  had  a  good  theoretic  train- 
ing beforehand,  with  the  amount  of  practical  application  of  their  training  given 
to  them  by  the  better  medical  schools  of  the  day,  they  will  be  prepared  very 
quickly  to  do  the  laboratory  work  on  the  wards  of  the  hospital  as  indicated  in 
another  part  of  this  section,  and  especially  will  this  be  true  if  the  attending  physi- 
cians in  the  institution  are  sufficiently  well  informed  about  laboratory  practice 
and  laboratory  technic  to  at  least  prevent  indifferent  or  hasty  work.  A  pretty 
safe  method,  with  an  adequate  check  on  the  results,  is  to  have  the  junior  intern, 
following  his  preliminary  training  in  the  laboratory,  do  all  the  work  relating  to 
his  patients  excepting  the  bacteriology  and  surgical  pathology.  By  this  method 
the  junior  intern  will  have  his  senior  to  check  him  up,  and  then  both  of  them  will 
have  not  only  the  attending  physician,  but  the  expert  laboratory  directors. 

Most  of  the  better  hospitals  of  the  time  include,  as  a  part  of  their  staff  organi- 
zations, certain  of  the  younger  practitioners,  ex-interns,  perhaps,  who  prosecute 
special  work  on  the  wards  along  the  lines  of  a  general  scheme  of  investigation. 
These  men  not  only  bring  fame  to  the  institution  in  which  they  work  by  the  pub- 
lication of  their  researches,  not  only  are  of  vast  benefit  to  patients  by  the  advanced 
scientific  work  they  do  in  diagnosis,  and  during  the  progress  of  disease  in  the  way 
of  guidance  in  diet,  medication,  and  general  or  special  treatment,  but  they  stimu- 
late similar  activity  on  the  part  of  the  intern  corps;  where  these  associate  staff 
members  are  encouraged  it  will  be  found  that  the  whole  trend  of  the  institution 
is  toward  high  ideals,  extending  to  the  every-day  care  of  patients,  better  history- 
taking,  more  careful  physical  examinations,  more  accurate  laboratory  investiga- 
tions as  a  part  of  the  general  practice,  and  a  high  order  of  service  in  every  direc- 
tion. 

Where  the  Work  is  Done. — In  some  institutions  all  laboratory  work  is  done 
at  one  central  point.  Elsewhere  a  part  of  the  work  is  done  in  small  laboratories, 
scattered  about  the  wards  or  floors  of  the  institution. 

In  the  first  plan  of  work  all  specimens  of  whatever  nature,  and  from  what- 
ever part  of  the  institution,  are  brought  to  the  laboratory  properly  labelled,  and 
accompanied  by  a  request  from  the  physician  for  the  kind  and  extent  of  the  work 
he  requires.  A  blank  form  of  this  sort  is  shown  in  the  section  on  Records  of 
Patients.  There  are  some  advantages  to  this  method  of  operating  the  service, 
the  chief  of  which  is  the  reliability  of  the  work  done,  because  it  will  all  be  done 
under  the  direction  and  personal  supervision  of  the  trained  men  paid  for  that 
purpose. 

In  the  second  method  there  is  a  central  laboratory  for  the  more  important 
work,  and  the  small  auxiliary  laboratories  located  about  the  institution,  conve- 
nient to  the  larger  wards,  where  the  simpler  work  can  be  done  by  interns  on  the 
various  services.  This  is  an  excellent  plan,  and  has  many  advantages  and  one  or 
two  disadvantages. 

There  is  a  great  deal  in  the  personal  touch  of  the  attending  physician  with  his 
patient,  and,  whether  it  lie  a  clinical  finding  or  a  laboratory  discovery,  the  physi- 
cian will  usually  want   to  see  the  result  of  whatever  technic  is  applied,  and  he  can 


382  OPERATION    OF  THE    HOSPITAL 

only  do  this  where  the  work  is  done  on  the  floors  where  he  can  see  the  slide  or 
specimen  without  going  a  long  distance  to  the  central  laboratory.  Moreover, 
there  is  a  good  deal  in  the  personal  equation  as  applied  to  the  men  doing  the  work. 
When  a  specimen  is  sent  to  the  central  laboratory  it  is  merely  a  specimen  in  the 
abstract,  and  has  no  identity,  no  significance,  and  no  special  interest  concerning 
any  particular  patient  or  disease,  in  which  case  there  is  greater  likelihood  that  the 
worker  will  rush  the  examinations  in  a  routine  way  as  a  part  of  an  uninteresting 
day's  labor.  It  may  be  a  case  of  nephritis  that  has  been  running  in  the  institution 
for  weeks,  and  the  albumin  content  of  the  urine  will  be  the  only  thing  that  the 
physician  requires,  and  he  not  only  wants  to  know  the  quantity,  but  he  will  want 
to  have  some  sense  of  proportions  and  comparisons  from  day  to  day.  Perhaps 
one  man  in  the  laboratory  will  make  the  examination  to-day  and  another  man 
to-morrow,  and  the  personal  equation  in  such  case  is  entirely  lost,  and  it  resolves 
itself  into  a  purely  technical  affair,  and  the  work  is  rushed  through ;  whereas,  if  the 
examination  is  made  on  the  ward  by  the  intern  on  the  case,  for  the  benefit  of  the 
attending  physician,  the  examination  can  take  on  a  personal  relation,  and  a  com- 
parison can  be  made  from  day  to  day  which  will  not  only  be  illuminating,  but  an 
immense  saving  of  time,  because  of  the  fact  that  only  an  albumin  test  need  be  made, 
which  takes  a  moment;  whereas,  if  it  were  clone  in  the  central  laboratory  a  complete 
urinalysis  would  have  to  be  made  every  time,  which  is  a  vastly  different  matter, 
and  occupies  a  good  deal  of  time. 

Equipment  of  Ward  Laboratories. — These  small  auxiliary  laboratories  need 
not  be  imposingly  placed  or  elaborately  equipped.  If  the  institution  is  not  very 
new  and  specially  provided  with  such  rooms  or  spaces  a  table  in  a  corner  of  the 
ward  will  answer  the  purpose,  or,  preferably,  a  nook  in  some  room  or  alcove  out- 
side, because  the  smell  of  boiling  urine  is  not  a  pleasant  one  for  patients.  The 
simple  reagents  for  sugar  and  albumin,  a  small  hand  or  water  or  electric  centrifuge, 
a  microscope  and  slides,  a  blood-counter,  a  hemoglobin,  and  a  blood-pressure 
apparatus  will  be  all  sufficient.  A  garbage  can  with  tight  cover  will  be  found 
convenient  as  an  inducement  toward  neatness.  Hot-  and  cold-water  faucets  are 
desirable,  but  not  absolutely  necessary. 

THE  CENTRAL  LABORATORY 

It  makes  no  difference  how  many  rooms  are  employed  for  the  central  labora- 
tory, the'  equipment  will  be  practically  the  same.  The  urines,  the  bacteriology, 
the  surgical  pathology,  and  the  postmortem  processes  must  be  done,  and  space 
must  be  employed  within  which  to  do  them.  For  convenience  of  operation,  and 
so  that  the  people  engaged  in  the  different  phases  of  the  work  can  have  their  own 
things  and  be  undisturbed  while  they  are  working,  a  series  of  rooms,  however  small, 
should  be  available,  and  we  can  now  proceed  to  the  equipment  for  this  work, 
taking,  first,  certain  of  the  fixtures  that  will  be  common  to  the  whole  suite. 

The  Instruments  and  Apparatus. —  The  Microscopes. — Perhaps  the  most 
important  instrument  of  the  laboratory  is  the  microscope,  and,  as  it  is  to  be  used 
for  several  purposes,  one  instrument  will  not  be  enough;  and,  even  if  the  most 
expensive  instruments  are  available  for  the  central  laboratory  plant,  there  will 
have  to  be  other  instruments,  vastly  cheaper,  if  some  of  the  laboratory  work  is 
to  be  done  on  the  wards  of  the  hospital. 

The  Zeiss  instrument  seems  to  meet  with  the  greatest  satisfaction  for  central 
laboratory  purposes,  and  then,  in  the  order  of  preference,  might  be  named  the  Leitz, 
Spencer,  and  the  Bausch  and  Lomb.  The  Zeiss  is  an  expensive  instrument,  and 
for  nearly  all  purposes  will  not  be  superior  to  the  Leitz  microscope,  and  the  cheaper 


DEPARTMENT  OF  PATHOLOGY  383 

makes  of  any  of  these  firms  will  serve  all  the  purposes  of  the  smaller  laboratories. 
A  very  good  instrument  for  the  interns  to  use  can  be  purchased  for  about  $75. 
Unfortunately,  hospitals  not  connected  with  an  educational  institution  must  pay 
import  duties  on  foreign-made  microscopes,  since  the  law  does  not  permit  hospitals 
to  import  free  of  duty;  the  laws,  too,  are  very  strict,  and  the  government  watchful 
to  see  that  instruments  bought  by  an  educational  institution  that  may  import  them 
free,  are  not  used  by  an  institution  not  allowed  to  import  free.  The  law  is  wrong, 
of  course,  and  if  any  institution  ought  to  be  allowed  to  import  needful  apparatus 
free  it  is  the  hospital. 

The  Incubator. — The  incubator  is  the  most  important  piece  of  apparatus  in  the 
bacteriologic  room,  used  principally  in  growing  cultures.  There  are  two  types  of 
incubators  purchasable  on  the  market,  one  in  which  the  heat  is  furnished  by  means 
of  the  electric  current  and  the  other  by  gas.  Experience  has  shown  that  the  gas 
regulators,  owing  to  the  variation  in  the  pressure  of  the  gas  and  the  amount  of  dirt 
the  gas  sometimes  contains,  are  frequently  difficult  of  accurate  regulation,  and,  of 
course,  a  constant  temperature  at  the  desired  point  is  the  prime  requisite  in  a 
laboratory  incubator.  Quite  recently  an  electric-heated  incubator  has  come  into 
the  market  and  promises  much  more  than  the  gas  type.  One  of  the  difficulties 
in  the  way  of  maintaining  a  constant  temperature  in  these  incubators  is  that  most 
of  them  have  a  water  jacket  composed  of  copper,  and  copper  is  an  excellent  heat 
conductor,  so  that  variations  outside  the  mechanism  act  quickly  upon  its  interior. 
Experiments  are  now  being  made  with  an  incubator  heated  with  electricity  that  is 
composed  of  an  outer  jacket  of  wood  with  copper  lining  and  asbestos  or  magnesia 
wool  between,  and  theoretically,  as  well  as  in  practical  service,  this  promises  to 
solve  the  temperature-regulation  difficulties. 

Laboratory  Sterilizers. — In  some  laboratories  there  is  a  special  steam  chamber 
for  the  purpose  of  sterilizing  culture-media  and  destroying  cultures  of  pathogenic 
bacteria.  A  better  method  of  destruction  of  these  micro-organisms  and  a  better 
mechanism  for  various  sterilizing  purposes  is  the  common  autoclave,  and  the  one 
that  seems  to  be  most  satisfactory  is  that  made  by  the  Bramhall-Deane  Co.  This 
autoclave  is  very  simple  in  construction,  is  easily  operated,  has  no  complicated  sys- 
tem of  bolts  and  wheels,  and  can  be  used  either  with  high-pressure  steam  from  the 
engine-room,  or  by  means  of  a  small  boiler  with  gas  flame  located  under  the  mechan- 
ism. We  have  dilated  more  on  the  good  points  of  the  Bramhall-Deane  sterilizer 
for  laboratory  purposes  in  the  general  section  on  Sterilizers. 

Another  sterilizer  of  great  use  in  the  laboratory  is  one  in  which  the  sterilization 
can  be  accomplished  by  means  of  steam  not  under  pressure,  and  a  serviceable  type 
of  this  sterilizer  is  that  known  as  the  Arnold.  This  type  has  the  door  opening 
from  the  front  rather  than  from  the  top.  This  instrument  is  almost  imperative 
for  the  preparation  of  certain  of  the  culture-media. 

The  Microtomes. — Every  laboratory  should  be  equipped  with  three  microtomes: 
a  paraffin  microtome,  a  celloidin  microtome,  and  a  freezing  microtome,  with  the 
necessary  attachments  for  each.  For  the  freezing  microtome  carbon  dioxid  gas 
is  the  preferable  method  of  freezing  tissues,  and  the  gas  is  best  dispensed  from  the 
ordinary  tank  of  commerce.  This  tank  can  be  fastened  to  the  wall  lying  on  its 
side,  or  even  placed  under  the  table  on  its  side,  and  the  microtome  can  be  con- 
veniently attached  to  the  table  itself.  This  microtome  is  usually  equipped  with 
small  copper  tubing,  leading  from  the  tank  to  the  instrument  with  the  proper 
attachments,  and  this  copper-tubing  method  of  attachment  seems  to  be  preferable 
to  the  direct  connection  of  the  microtome  to  the  tank,  because  of  a  very  much  greater 
convenience  in  arrangement. 


384  OPERATION   OF   THE    HOSPITAL 

For  all  work  a  large,  heavy  machine  is  required  for  accuracy,  and  there  seems  to 
be  hardly  a  choice  between  any  of  the  standard  makes  offered  for  sale.  Recently 
a  comparatively  new  type  of  machine  has  been  placed  on  the  market,  which  can  be 
used  for  either  paraffin  or  celloidin  work;  this  is  the  "wedge  base"  microtome. 

The  Paraffin  Oven. — The  paraffin  oven  for  embedding  tissues  is  essential  in 
the  pathologic  room,  and  the  particular  type  of  oven  that  seems  to  be  in  favor  with 
the  pathologists  is  that  shaped  like  a  box  and  opening  from  the  front,  and  in  which 
the  paraffin  cups  are  placed  inside  the  box. 

Floors  of  the  Laboratory. — The  floors  of  laboratories  should  not  be  of  wood, 
because  they  stain  easily  and  are  eaten  away  by  acids;  nor  should  they  be  of 
monolithic  compounds,  or  stone  or  tile,  because  of  the  far  greater  glass  breakage  in 
a  room  with  a  stone  floor.  The  best  flooring  for  a  laboratory  is  linoleum,  and  more 
especially  the  heavy  "battle-ship"  linoleum,  of  a  single  color,  a  quiet  brown  or  gray. 
If  these  linoleums  are  oiled  occasionally  with  a  very  little  boiled  linseed  oil,  and  the 
oil  rubbed  in  carefully,  they  do  not  admit  of  the  eating  processes  of  acids  and  re- 
agents to  any  great  degree,  and  will  keep  in  good  order  and  be  presentable  for  a 
long  time. 

If  it  is  a  new  building  to  be  equipped,  the  concrete  subfloor  is  made  with  a 
cove  base  extending  several  inches  out  on  the  floor  from  the  wall,  and  then  a  drop 
in  the  concrete  amounting  to  the  thickness  of  the  linoleum,  which  is  cut  to  exactly 
the  right  size,  and  set  into  this  frame  with  the5  regular  cement  sold  for  the  purpose. 

The  Laboratory  Hoods. — An  important  thing  to  consider  in  the  construction 
of  the  hood  is  the  flue  leading  from  it.  If  the  building  is  high  and  the  flue  extends 
to  the  roof  it  may  not  be  necessary  to  have  an  exhaust  fan  at  the  exit,  especially 
where  large  burners  can  be  placed  at  the  lower  opening.  In  small  buildings,  and 
especially  where  the  flue  either  does  not  go  to  the  roof  of  the  building,  or  where  the 
roof  of  the  building  is  below  the  roofs  of  adjoining  structures,  it  will  probably  be 
necessary  to  have  such  an  exhaust  fan  to  draw  out  the  fumes  of  gases,  acids,  and  the 
like. 

In  most  of  the  hoods  in  the  new  laboratories  there  are  double  openings — the 
main  one  at  the  top  of  the  hood  to  carry  off  the  lighter  gases,  and  the  other,  near 
the  bottom,  carries  off  the  heavier  gases.  It  is  well  in  such  a  hood  to  have  a  large- 
caliber  lead  piping,  with  holes  in  the  side,  and  with  an  outlet  leading  to  the  upper 
opening  in  the  hood  for  the  purpose  of  oxidation. 

The  framework  of  hoods  may  be  prepared  either  of  woods  treated  with  a  fire- 
proof paint  or  of  steel  coated  with  some  paint  that  will  not  be  affected  by  acids, 
gases,  or  fumes.  It  is  the  feeling  of  a  majority  of  chemists  that  wooden  hoods  are 
preferable,  because,  in  spite  of  the  paint,  steel  work  rusts,  and  it  is  impossible  to 
maintain  the  hood  so  that  it  will  be  presentable.  The  bottom  of  the  hood  is  usually 
composed  of  a  slab  of  albaline,  and  under  the  floor  there  may  be  shelves  for  keeping 
various  utensils,  and  for  appearance  the  shelves  may  be  enclosed  with  small  doors. 
Leading  to  the  hood  are  pipes  for  cold  water  and  gas,  and  a  small  opening  should 
be  left  in  the  floor  of  the  hood  for  the  exit  of  waste  water.  Fig.  144  shows  an  excel- 
lent form  of  hood  that  can  be  connected  with  any  flue. 

Laboratory  Sinks. — There  is  now  made  a  porcelain  sink,  about  2  by  3  feet  in 
the  bowl,  with  a  flat  bottom,  on  which  acids  and  stains  make  but  slight  impression, 
and  this  particular  form  of  sink  can  well  be  used  in  all  places  employed  in  labora- 
tory work.  In  order  that  the  breakage  of  glassware  may  be  reduced  to  a  minimum 
there  is  a  wooden  slab  made  to  fit  the  bottom  of  the  sink,  with  an  end-piece  at  each 
end  rabbited  in  so  that  the  board  cannot  warp.  Small  auger-holes  are  bored  at 
intervals  in  the  board,  or  the  slab  may  be  a  slatted  affair  made  of  crossed  pieces, 


DEPARTMENT   OF    PATHOLOGY 


:;n:, 


leaving  open  squares  '-inch  in  diameter.  This  bottom  can  he  painted  with  a 
waterproof  paint,  or  with  a  preparation  such  as  we  shall  hereafter  discuss  as  a  cover- 
ing for  laboratory  tables  and  wooden  furniture.  Glassware  falling  on  this  wooden 
bottom  will  not  break  so  easily,  and  the  saving  in  specimen  bottles  alone  will  be 
considerable. 

The  Test-tube  Board. — There  is  a  board  for  the  back  of  and  just  over  the  sink 
that  will  be  found  extremely  useful.     It  is  merely  a  dressed  board,  perhaps  2  feet 


Elevati  ON- 


JDECTION  -A-B- 


~-F,L_/\l\l 


Fig.  144. — Laboratory  room  hoods. 

square,  with  rabbitted  ends  to  prevent  warping,  with  a  lot  of  wooden  pegs  driven 
in  so  that  when  the  board  is  fastened  over  the  sink  the  pegs  will  point  upward  at  a 
slight  angle  as  they  leave  the  wood.      They  should  be  large  pegs,  and  driven  in  so 

that  about  2'  or  3  inches  of  the  length  protrudes.  After  specimen  bottles  and  test- 
tubes  are  washed  they  can  be  stuck  on  these  pegs,  and  they  dry  OUl  quickly  and 
effectively,  because  the  sag  of  the  bottle  permits  all  of  the  water  t<>  tun  away. 
This  board  should  also  be  painted  with  a  stain-proof  paint,  and  will  then  not  be 
affected  by  water  or  the  operations  of  the  sink. 

25 


386  OPERATION   OF   THE   HOSPITAL 

Tables  and  Work-benches. — Modern  laboratories  are  no  longer  lumbered  up 
with  high  work-tables  in  the  middle  of  the  room,  interfering  with  the  freedom  of 
movement  on  the  part  of  the  workers,  who  must  move  quickly  from  one  part  of 
the  room  to  another.  The  tables  and  work-benches  are  now  nearly  always  fastened 
to  the  wall.  They  are  narrow,  as  a  rule,  extending  out  not  more  than  2  feet,  or 
even  20  inches  from  the  wall,  and  they  should  be  of  convenient  height,  so  that  the 
worker  may  sit  in  an  ordinary  chair,  say,  about  30  inches  high.  There  should  be  wall 
cases  almost  everywhere  in  the  laboratory  to  contain  bottles,  small  and  large; 
otherwise  the  laboratory  tables  will  always  be  littered  up  with  an  infinite  number  of 
bottles  nearly  all  of  which  will  be  out  of  place  and  impossible  to  find  when  wanted. 
The  doors  and  frames  of  these  cases  may  be  painted  any  agreeable  color. 

Paint  for  Tables  and  Furniture. — It  has  always  been  a  great  problem  in  labora- 
tories to  find  a  table  or  work-bench  top  that  would  not  be  constantly  stained  with 
acids  and  reagents.  Marble  and  stone  are  impossible,  because  whatever  falls  on 
them,  no  matter  how  short  a  distance,  will  be  broken.  Wood,  as  it  is  ordinarily 
treated,  or  as  it  is  ordinarily  painted  and  varnished,  is  impossible  because  of  the 
acids,  reagents,  and  stains  that  fall  upon  it.  Of  late  years  there  has  been  devised 
a  preparation  that  seems  to  meet  all  the  requirements,  and  the  formula  is  herewith 
given  with  the  method  of  its  application: 

Five  Solutions 

(a)     Potassium  chlorate 10  gm. 

Copper  sulphate 10  gm. 

Water 1000  c.e. 

Apply  two  coats  of  the  hot  solution.  Allow  first  to  dry  before  applying  the  second.  Allow 
to  dry  and  wash  with  water. 

(6)     Anilin  hydrochlorid 12  gm. 

Water 1000  c.c. 

Apply  one  coat.     Allow  to  dry. 

(c)  Potassium  bichlorate,  10  per  cent,  in  water. 
Apply  one  coat.     Allow  to  dry. 

(d)  Hydrochloric  acid,  5  per  cent,  in  water. 
Apply  one  coat.     Allow  to  dry  and  wash  with  water. 

(e)  Linseed  oil. 
Iron  in  with  hot  iron. 

These  five  processes  are  applied,  one  after  another,  as  soon  as  dry,  a  day  or  two 
between  each  coat,  and  several  days  should  elapse  after  the  oil  is  applied  to  allow 
the  furniture  to  dry  thoroughly. 

Slide  Cases. — Probably  the  most  satisfactory  method  of  filing  pathologic  slides 
is  consecutively,  and  placing  them  in  long  boxes,  which  are  then  subdivided  in  such 
a  manner  that  the  slides  will  rest  on  their  ends.  If  in  doing  this,  certain  slides, 
every  fiftieth,  for  instance,  have  a  number  projecting  free  above  the  level  of  the 
other  slides,  it  would  be  easy,  by  thumbing  the  exposed  ends,  to  find  ony  one 
wanted.  If  slides  do  not  accumulate  too  rapidly  a  very  nice  method  of  doing  this 
is  to  use  the  ordinary  card-filing  case,  subdivided  as  above  described.  In  keeping 
such  records  it  is  necessary,  in  order  that  quick  access  may  be  had  to  any  par- 
ticular case,  that  three  records  be  kept,  one  in  a  large  book  containing  consecutive 
numbers,  opposite  each  of  which  is  to  be  found  the  patient's  name  and  hospital 
number,  doctor's  name,  nature  of  material  and  date.  This  book  serves  to  keep 
track  of  the  serial  numbers.     In  addition  to  this  book  there  should  be  a  cross-card 


DEPARTMENT   OF   PATHOLOGY  387 

index — one  index  should  show  the  name  of  the  patient,  arranged  alphabetically, 
and  the  other  the  organ.     By  this  method,  if  it  is  desired  at  any  time  to  obtain  the 

pathologic  findings  of  any  case,  or  the  particular  disease  of  any  organ,  it  will  only 
lie  necessary  to  turn  to  that  organ  in  order  to  find  not  only  the  number  of  tin- 
case  and  the  diagnosis  attached,  but  also  the  name  of  the  patient,  and  in  this  way 
the  case  histories  can  lie  found.  In  many  instances  the  index  will  be  used  only  to 
find  the  diagnosis  in  the  ease  of  a  certain  patient,  and  here  it  is  only  necessary  that 
we  have  the  name.  It  is  believed  that  by  this  arrangement  an  accurate  record  can 
be  kept  of  all  specimens  coming  to  the  laboratory. 

Lights  for  Night  Work. — The  ordinary  gaslight  and  electric  light  are  wholly 
unfitted  for  the  purposes  of  the  microscope,  and  a  convenient  light  for  this  work  is 
a  small  white-frosted  electric-light  bulb,  which  can  be  attached  to  a  block  of  wood 
and  placed  in  any  required  position  on  the  work-table,  or  a  Welsbach  may  be 
used.     These  lights  must  be  movable  of  course. 

The  Dark  Room. — An  essential  part  of  a  good  pathologic  department  is  a  dark 
room,  necessary,  of  course,  if  there  is  microphotography,  and  extremely  useful  for 
the  polariscope.  The  ordinary  dark  room  of  the  photographic  studio  will  answer 
every  purpose,  and  the  room  need  not  be  a  large  one. 

The  Postmortem  Room. — There  seems  to  be  a  disposition  on  the  part  of  archi- 
tects and  hospital  administrators  to  place  the  postmortem  room  and  the  refrigera- 
tors for  the  dead  in  almost  any  out-of-the-way  place  not  needed  for  other  purposes, 
and  wholly  regardless  of  the  lighting  and  ventilation.  That  this  is  a  great  mistake 
will  become  obvious  to  any  one  who  will  take  the  trouble  to  visit  a  number  of 
hospitals.  Where  there  is  a  well-lighted,  well-ventilated,  comfortable  room  in 
which  to  work,  the  postmortem  room  is  one  of  the  interesting  places  of  the  insti- 
tution, and  it  will  be  found  that  when  there  are  no  postmortems  to  be  done,  the 
interns,  and  more  especially  the  younger  attending  physicians  and  surgeons,  will 
frequent  the  room,  prosecuting  their  studies  there,  anatomically,  either  on  the 
bodies  of  the  dead  or  the  bodies  of  lower  animals.  If  the  room  is  dark,  ill-venti- 
lated, and  uninviting,  no  work  will  lie  in  progress  and  it  will  be  a  neglected 
place. 

Besides  good  light  and  good  ventilation  there  should  be  a  good  refrigerator,  large 
enough  to  hold  not  only  the  bodies  of  those  who  die  until  they  can  be  removed, 
but  with  a  compartment  to  contain  anatomic  parts.  The  postmortem  room  refrig- 
erator is  of  some  moment,  the  crates  for  the  box  being  the  most  important  part. 
In  a  great  many  postmortem  refrigerators  there  is  a  plain  slatted  slab  on  which  to 
lay  the  body,  and  it  is  difficult  to  get  the  body  in  and  out  on  this  slab,  and  gener- 
ally two  boxes  are  needed  or  two  stools,  and  it  is  a  back-breaking  process. 

A  very  convenient  mechanism  is  a  double-slide  arrangement,  on  the  principle 
of  double-door  elevators,  where  one  door  goes  part  way  out  and  in  and  the  sec- 
ond door  goes  the  other  part  of  the  way.  The  mechanism  is  on  a  double  se1  of 
wheels,  and  the  sides  of  the  slab  operate  in  a  groove,  and  act  as  a  lever  to  hold 
the  body  in  suspension,  even  after  it  is  three  parts  of  the  way  out  of  the  box. 
The  sides  of  the  slab  ought  to  lie  of  heavy  stuff,  either  metal  or  strong  wood,  pref- 
erably 2  by  G  inch  pieces  of  oak,  the  full  length  of  the  refrigerator,  and  the  crate 
is  built  up  between  these  side  pieces. 

Most  postmortem  refrigerators  are  now  cooled  by  nitrous  oxid  or  ammonia 
pipes  as  a  pari  of  the  general  refrigeration  scheme  of  the  hospital.    Ice  can  be  used 

above  the  boxes  where  there  is  no  refrigeration  system. 

The  floor  of  the  postmortem  room  should  beof  cement,  sloping  from  all  sides 
to  a  central  trapped  drain,  which  may  be  placed  under  the  table.    The  walls 


388  OPERATION   OF   THE   HOSPITAL 

should  be  of  some  material  that  will  permit  of  washing  with  a  hose,  and  to  this 
end  the  room  ought  to  be  as  free  as  possible  from  everything  excepting  the  appa- 
ratus to  be  used  in  postmortem  work.  If  there  be  a  small  amphitheatre,  so  that  an 
audience  can  attend  autopsies,  there  should  be  at  least  a  6-foot  solid  wall  between 
the  arena  and  the  audience  seats,  so  that  at  least  the  arena  can  be  kept  clean  and 
sweet. 

There  must  be  a  sink  with  a  large  bowl,  stoppered  at  the  bottom,  for  hot  and 
cold  water.  It  may  be  necessary  oftentimes  to  wash  large  organs,  and  the  sink 
ought,  therefore,  to  be  made  so  it  will  hold  water.  In  some  operating-rooms 
there  is  a  cold  water  outlet  with  hose  attachment  over  the  operating-table;  experi- 
ence does  not  develop  a  great  amount  of  usefulness  for  water  above  the  table,  and 
the  use  of  water  at  that  point  is  disagreeable  and  oftentimes  splashes  over  the 
clothing  and  faces  of  the  people  at  work.  A  bucket  of  water  and  a  large  sponge  serve 
the  purpose,  or,  better  still,  an  open-mouth  small  hose  at  the  side  of  the  table, 
worked  with  a  self-closing  faucet. 

The  Postmortem  Table. — Just  how  the  postmortem  table  should  be  arranged 
is  a  mooted  question,  and  various  types  have  been  recommended.  A  very  good 
scheme  is  the  one  used  at  the  Massachusetts  General  Hospital  in  Boston.  This 
table  is  arranged  in  the  form  of  a  box  about  a  foot  deep,  and  either  composed  of,  or 
covered  with,  sheet  iron.  Across  the  top  of  this  box  is  stretched  iron  netting, 
with  rather  close  meshwork  to  prevent  instruments  and  tissues  falling  through  into 
the  box  below.  At  the  bottom,  in  the  central  part,  is  a  large  outlet  for  fluids  and 
water.  The  water  pipe  extends  through  the  bottom  almost  to  the  top,  and  is 
here  connected  with  rubber  tubing,  which,  in  turn,  is  connected  with  a  copper 
receptacle  measuring  about  18  inches  in  length,  about  12  in  width,  and  about 
12  in  depth.  The  rubber  tubing  is  connected  with  the  bottom  of  this  receptacle, 
which  can  be  moved  to  any  portion  of  the  table  desired.  As  the  water  is  allowed 
to  flow  continuously  into  this  vessel  during  the  postmortem,  it  will  be  seen  that 
one  great  advantage  of  this  type  of  table  is  that,  regardless  of  where  the  vessel 
may  be  placed,  the  overflow  will  run  through  the  iron  meshwork  and  not  over  the 
surface  of  the  table  and  on  the  floor,  as  occurs  in  so  many  old-fashioned  marble- 
top  tables.  The  marble-top  table  as  usually  made  for  this  purpose  is  of  doubtful 
advantage,  owing  to  the  sloppy  appearance  which  it  generally  presents,  and  to  the 
fact  that,  when  a  body  is  on  the  table,  the  central  opening,  which  is  supposed  to 
allow  the  escape  of  fluids,  is  usually  blocked  by  the  body  itself,  thus  defeating  the 
purpose  for  which  it  is  intended. 

The  placing  of  a  fan  at  the  side  of  the  outlet,  such  as  is  done  in  the  Massa- 
chusetts General  Hospital,  to  suck  away  the  odors  which  are  usually  present  is  a 
very  good  scheme,  but  in  many  places  hardly  practicable. 

The  Animal  Room. — Every  hospital  should  keep  at  least  a  few  animals  for 
pathologic  purposes,  and  the  larger  institutions  will,  of  course,  keep  many  animals 
of  the  smaller  varieties,  like  rabbits,  guinea-pigs,  rats,  and  mice.  Even  where  no 
research  work  is  done,  and  where  no  educational  activities  are  contemplated,  guinea- 
pigs  will  often  be  required  in  the  diagnosis  of  tuberculosis,  for  instance,  and  this 
work  at  least  is  necessary  for  diagnostic  purposes. 

If  proper  quarters  are  provided  for  these  small  animals  they  ought  not  to  be 
very  expensive  or  give  very  much  trouble — guinea-pigs,  especially,  increase  rapidly 
and  thrive  under  any  sort  of  decent  conditions.  The  other  annuals — rabbits, 
rats,  and  mice — do  not  do  so  well  except  under  the  most  favorable  conditions. 
Rabbits  are  subject  to  an  infinite  number  of  skin  diseases  and  catarrhal  affections 
and  epidemics  of  one  sort  and  another,  and,  when  the  stock  has  to  be  replenished 


DEPARTMENT  OF   PATHOLOGY  M.N!) 

from  the  outside,  oftentimes  an  epidemic  will  strike  the  burrow  and  destroy  them 
all. 

Rats  and  mice  eat  their  young  if  they  are  not  fed  properly,  and  they,  too,  are 
subject  to  diseases  of  many  sorts. 

It  appears  that  almost  always  the  darkest,  dampest,  and  dingiest  room  in  the 
house  is  selected  as  the  quarters  for  the  animals,  and  then  the  hospital  manage- 
ment wonders  that  it  has  had  luck  with  its  stock  animals.  All  these  little  animals 
ought  to  be  kept  above  the  ground  and  in  well-lighted  quarters,  and  their  habita- 
tions ought  to  lie  kept  clean.  Rabbits,  at  least,  ought  to  have  a  runway,  and  if 
they  have  a  burrow  out  in  the  yard,  and  are  allowed  to  increase  without  the  advent 
of  new  stock  from  the  outside,  and  are  properly  fed  on  cabbage-leaves,  new  grass, 
carrots,  potatoes,  and  turnips,  they  will  thrive  nicely  and  keep  in  good  condition. 
It  does  not  make  so  very  much  difference  about  the  size  of  the  stock  cages,  but 
there  ought  not  to  be  too  many  animals  in  a  cage.  A  dozen  or  twenty  guinea-pigs 
will  thrive  and  breed  rapidly  in  a  cage  5  or  6  feet  long  and  3  feet  wide,  made  out  of 
small  mesh-wire.  A  half-dozen  rabbits  can  be  kept  in  such  a  cage,  but  they  will 
not  breed  satisfactorily  unless  they  can  get  into  the  ground  and  have  more  room 
and  some  seclusion. 

The  inoculation  cages  for  both  rabbits  and  pigs  are  usually  24  inches  long,  17^ 
inches  wide,  and  15|  inches  high.  The  animals,  after  inoculation,  need  very  little 
room,  and  the  cages  can  be  kept  close  together. 

The  room  in  which  the  animals  are  kept  ought  to  be  so  arranged  that  a  hose 
can  be  turned  on  it,  and  it  should  be  possible  to  seal  it  perfectly  so  that  it  can  be 
given  a  formaldehyd  fumigation  whenever  necessary. 

Frozen  Sections. — Every  modern  institution  that  pretends  to  do  surgical  work 
undertakes,  or  should  undertake,  to  aid  the  surgeon  in  the  establishment  of  his 
diagnosis  while  the  patient  is  on  the  table,  and  so  quickly  after  the  tissue  is  taken 
that  the  operator  may  have  the  advantage  of  his  finding  in  the  final  disposition  of 
his  surgical  procedure.  For  instance,  there  is  a  breast  tumor  to  be  removed.  It 
is  axiomatic  with  surgeons  that  every  tumor  of  the  female  breast  is  guilty  of  malig- 
nancy until  it  is  proved  innocent,  and  if  immediately  after  the  tumor  is  removed  a 
frozen  section  can  be  made  of  the  tissue  at  several  points  of  the  tumor,  and  a  reli- 
able diagnosis  of  innocence  can  be  made,  the  surgeon  will  be  enabled  to  close  up 
his  wound  and  limit  the  operation  to  the  actual  removal  of  the  tumor.  If  the  path- 
ologist finds,  however,  that  there  is  cancerous  tissue  or  suspicious  looking  tissue 
in  the  specimen  given  to  him,  the  surgeon  will  want  to  invade  the  armpit,  remove 
any  glands  he  may  find  there,  and  remove  the  breast. 

Many  times  where  these  frozen  section  facilities  are  not  available,  the  sur- 
geon will  either  be  compelled  to  assume  the  gravest  character  of  the  disease  and 
so  prosecute  his  operation  to  perhaps  dangerous  lengths,  or  he  will  have  to  close 
the  wound,  with  the  possibility  that  he  may  have  to  do  a  second  stage  as  soon  a-  the 
laboratory  has  made  its  report  in  a  day  or  two  or  at  some  subsequent  time.  It 
is  true  that  frozen-section  pathology  is  not  nearly  so  valuable  and  trustworthy  as 
an  examination  of  tissue  done  by  the  longer  processes  possible  in  the  Central  labora- 
tory of  the  institution,  but,  for  the  immediate  purposes  of  the  surgeon,  the  frozen- 
section  method  is  imperative. 

A  very  small  equipment  is  required  for  this  frozen-section  work,  and  a  very 
small  space,  enough  for  a  table  2  by  3  feet  and  a  stool  for  the  pathologist, 
somewhere  convenient  to  the  operating  suite;  under  the  table  he  will  have  his 
tank  of  carbonic  acid  or  freezing  gas;  on  the  table  he  will  have  his  microtome,  a 
large  dish  of  water  for  the  handling  of  sections,  a  microscope,  a  box  of  slides  and 


390  OPERATION*    OF    THE    HOSPITAL 

cover-glasses,  with  the  few  bottles  of  stains  that  he  may  need.  The  technic  of  this 
frozen-section  work  is  clearly  within  the  realm  of  the  pathologist  and  has  no  place 
here. 

The  Museum. — Wherever  surgery  is  done,  or  any  attempt  is  made  to  do  inter- 
esting scientific  work,  either  upon  patients  or  in  an  educational  way,  there  ought 
to  be  a  pathologic  museum,  and,  however  humble  and  simple  such  a  room  appears, 
there  are  a  few  principles  that  must  be  considered,  the  chief  of  which  is  the  lighting 
scheme.  Bright  or  direct  fight  causes  the  colors  in  prepared  specimens  to  fade 
rapidly,  and,  therefore,  the  light  ought  not  to  be  too  great,  and  it  should  be  indi- 
rect; even  a  very  dark  room  may  be  used  for  museum  purposes,  with  electric  or  gas 
light,  to  be  turned  on  and  off  when  necessary;  or  the  windows,  if  the  room  is  well 
lighted,  should  be  of  dark-colored  glass  or  covered  with  some  dark  material,  such  as 
heavy  curtain  cloth ;  or  the  shelves  themselves  may  be  covered  with  drop  curtains, 
which  will  answer  the  same  purpose.  The  size  of  the  room  will  be,  of  course,  a 
question  that  will  depend  on  the  amount  of  work  to  be  done  and  the  character  of 
specimens  to  be  saved.  In  a  good  many  hospitals  everything  is  saved,  and,  where 
this  is  the  custom,  the  collection  is  usually  very  systematic  and  the  specimens  are 
tabulated  and  indexed  and  cross-indexed,  and  sometimes  there  is  even  a  triple 
index,  under  the  head  of  (a)  the  name  of  the  patient  and  number,  (b)  the  organ  from 
which  the  specimen  is  taken,  and  (c)  the  disease  illustrated  in  the  specimen.  If 
the  arrangement  of  specimens  is  properly  done  a  comparatively  small  room,  with 
ample  wall  shelving,  will  hold  an  immense  number  of  specimens,  and  then  a  double 
row  of  shelving  may  at  some  future  time  be  erected  in  the  center  of  the  room,  leav- 
ing a  walk-way  all  around.  In  some  hospitals  test-tubes  are  used  for  museum 
specimens,  such  as  the  appendix  specimens,  and  these  test-tubes  are  sealed  with  a 
cork  and  paraffin,  and  certain  classes  of  specimens  are  placed  together  in  boxes  or 
cans  and  indexed  so  they  can  be  immediately  found. 

The  Refrigerators. — In  some  part  of  the  laboratory  suite  there  must  be  a 
refrigerator,  preferably  in  the  bacteriologic  room.  The  size  of  this  refrigerator  is 
not  nearly  so  important  as  its  reliability  in  temperature.  If  the  institution  is 
large  and  serum  work  is  attempted  there  might  be  a  second  refrigerator  for  the  se- 
rums, and  if  there  are  two  refrigerators  the  problem  of  temperature  will  be  a  good 
deal  simplified.  Most  culture-media  with  contents  last  longer  at  a  temperature  of 
about  38°  F.  and  up  to  40°  F.  Serums  must  not  be  kept  above  about  45°  F.  and 
they  often  freeze  just  under  40°  F.,  after  which  they  are  worthless. 

The  refrigerator  can  be  connected  to  the  refrigeration  plant  of  the  institution, 
if  there  is  one,  and  the  ordinary  regulation  of  the  whole  plant  will  serve  all  the  pur- 
poses of  that  refrigerator,  but  very  careful  laboratory  men  find  great  difficulty  in 
maintaining  an  even  enough  temperature  and  one  that  can  be  accurately  controlled; 
they  sometimes  prefer  an  old-fashioned  ice-box,  in  which  a  block  of  ice  will  keep  to 
a  temperature  just  low  enough  without  clanger  of  freezing. 

PATHOLOGY  IN  THE  SMALL  HOSPITAL 

It  will  not  do  any  longer  for  even  the  smallest  and  most  unpretentious  hospital 
to  take  the  ground  that  it  cannot  afford  to  do  pathologic  work.  Pathology,  bac- 
teriology, urinology,  vaccine,  and  serum  therapy  are  very  much  more  a  part  of  the 
modern  practice  of  medicine  than  the  drugstore,  and  the  hospital  that  cannot  afford 
to  give  its  patients  these  diagnostic  and  therapeutic  advantages  cannot  afford  to 
exist,  and  will  be  a  menace  rather  than  a  help  in  the  community. 

But  it  will  not  be  necessary  for  a  small  institution  of  25,  50,  or  even  100  beds 


DEPARTMENT  OF    PATHOLOGY  391 

to  maintain  an  elaborate  pathologic  equipment.  Perhaps  one  good  man,  trained 
to  his  work,  will  be  sufficient,  with  an  assistant  in  the  person  of  an  intern  or  even  an 
intelligent  pupil  nurse,  or,  better  still,  a  permanently  employed  young  woman, 
fairly  intelligent  in  mind,  conscientious  in  method,  and  skilful  with  her  fingers. 
Almost  the  whole  expense  of  such  an  organization  will  be  the  salary  of  the  expert 
and  the  renewal  of  breakages.  The  original  equipment  for  a  sufficient  plant  under 
such  an  organization  can  be  provided  for  $800  or  §1000.  One  large  room  will 
serve  the  purpose,  or  a  large  room  and  a  small  one,  and  the  equipment  will  be 
pretty  well  satisfied  if  it  includes  an  ordinary  ice-box,  an  incubator,  a  single  steam 
sterilizer,  such  as  the  Bramhall-Deane,  which  costs  about  §125;  a  good  microscope 
at,  say,  S100;  one  microtome,  at  $75;  one  incubator,  at  $50;  a  centrifuge,  at  $50, 
because  a  cheaper  one  will  not  throw  down  bacteria;  and  then  a  few  pieces  of 
smaller  apparatus,  such  as  scales,  water-bath,  water-vacuum  filter,  all  of  which 
are  inexpensive,  and  the  necessary  glassware  and  reagents. 

Such  an  equipment  will  not  be  ample  to  do  a  great  deal  of  work,  and  will  neces- 
sarily be  limited  as  to  the  broadness  of  the  work,  because  no  man  will  be  found 
who  can  give  an  adequate  service  on  anything  like  a  workable  scale  in  the  urines, 
blood  examinations,  the  technical  tests,  and  at  the  same  time  make  blood-counts, 
hemoglobins,  blood-pressures,  and  do  the  vaccine  and  serum  work  on  the  patients 
in  the  institution. 

However,  where  the  institution  is  small,  there  will  probably  not  be  more  than  one 
or  two  attending  physicians  or  surgeons  who  would  appreciate  the  significance  of 
even  the  modest  work  outlined  here,  and  it  could  well  be  that  such  a  pathologist 
would  have  to  lead  and  inspire  the  attending  physicians  in  the  institution  rather 
than  be  overworked  by  them. 


THE  DEPARTMENT  OF  HYDROTHERAPY 

In  this  modem  day,  when  the  dosing  of  patients  is  on  the  decline,  and  dietary 
and  physical  therapy  are  on  the  increase,  every  institution  employed  in  the  care 
of  the  sick,  and  that  pretends  to  scientific  attainment,  must  be  equipped  with  at 
least  a  modicum  of  apparatus  for  hydrotherapeutic  treatment. 

While  it  is  not  the  purpose  in  this  book  to  discuss  disease  from  any  medical  stand- 
point, it  might  be  profitable  as  a  prelude  to  the  equipment  of  a  department  of  hydro- 
therapy to  very  briefly  consider  the  avenues  along  which  water  in  some  form  is  in- 
tended to  be  beneficial  in  the  cure  of  disease. 

It  may  be  stated  broadly,  at  the  outset,  that  water  is  employed  for  one  of  three 
primary  purposes: 

First,  as  a  means  for  the  introduction  of  certain  medicines,  more  especially  the 
mineral  salts. 

Second,  as  a  physical  agent,  by  which  the  skin  and  periphery  of  the  body  are 
irritated  or  stimulated  to  a  point  where  the  blood-vessels  dilate  as  an  invitation  to 
large  quantities  of  blood  to  leave  the  centers,  that  is,  the  internal  organs,  and  thus 
allow  those  organs  to  resume  a  function  that  has  been  greatly  impeded  by  what 
we  call  congestion. 

Third,  purely  for  its  mental  impression  on  patients,  especially  those  suffering 
from  some  form  of  nervous  disease. 

There  is  still  a  fourth  employment  of  water,  namely,  that  principle  used  in  the 
tubbing  of  typhoids,  pneumonias,  heat  prostrations,  and  the  like,  where  high 
temperatures  must  be  lowered  speedily;  but  hydrotherapy  is  hardly  to  be  thought 
of  in  this  connection,  and  no  special  apparatus  need  be  supplied  beyond  a  common 
bath-tub  or  wet  sheets. 

The  biblical  pool  of  Bethesda  was  an  illustration  of  medicinal  waters,  admin- 
istered to  the  outer  surface  of  the  body,  and  all  clown  the  ages  there  have  been 
"springs"  and  "baths"  whose  virtues  are  supposed  to  reside  in  certain  mineral 
salts  in  solution  in  the  waters.  These  curative  waters  are  scattered  everywhere 
about  the  earth,  and  some  of  them  have  earned  great  fame,  some  perhaps  justly, 
and  others  because  whatever  virtues  they  may  have  had  have  been  supplemented 
by  carefully  devised  courses  of  treatment,  diet,  and  exercise  in  adroit  and  skilful 
professional  hands. 

The  school  of  hydrotherapy  began  in  Germany,  and  was  known  as  a  water  cure 
or  "the  baths,"  because  patients  were  sent  to  towns  or  to  villages  in  which  there  were 
springs  of  some  supposed  virtue.  Patients  drank  the  waters  and  were  bathed  in 
them.  People  flocked  to  Germany  from  all  over  the  world  to  take  the  baths,  and 
they  did  so  because  there  were  many  cures  effected,  and  there  is  no  doubt  that 
many  of  these  cures  were  due  to  other  factors  besides  the  waters  and  the  baths; 
the  family  physician  ordered  his  patient  to  take  certain  baths  at  a  certain  place, 
and  sent  him  to  some  particular  specialist  there;  the  very  fact  of  this  order  aroused 
the  patient  to  a  realization  that  he  was  a  sick  man,  and  the  result  was  that  he  was 
in  a  mental  frame  of  mind  when  he  arrived  at  his  destination  to  place  himself  un- 
reservedly in  the  hands  of  his  physician  and  to  obey  orders.  These  orders  usually 
contemplated  diet  as  well  as  baths  and  drinks.     A  great  many  of  these  people 

392 


THE  DEPARTMENT  OF  HYDROTHERAPY  393 

were  in  those  days,  just  as  they  are  to-day,  troubled  with  functional  disturbances, 
due  either  to  indiscretion  in  living,  diet,  or  dissipation,  or  to  the  strenuous  business 
lives  they  were  living.  Such  a  patient,  placed  on  a  restricted  diet,  given  regular 
exercises,  and  drenched  pretty  well  with  water — no  matter  what  kind — was  almost 
bound  to  be  benefited. 

The  German  waters  in  this  way  have  become  famous  for  their  curative  prop- 
erties, and  Germany  has  built  up  an  immense  industry,  especially  in  such  cities 
as  Nauheim,  Carlsbad,  and  Baden-Baden. 

The  prosperity  of  the  German  watering-places  called  forth  a  great  number 
of  imitators,  and  people  in  all  parts  of  the  world  began  to  exploit  springs  of  various 
sorts,  and  it  made  very  little  difference  what  was  the  nature  of  the  water  or  its 
temperature,  so  that  it  was  in  some  one  thing  out  of  the  ordinary.  In  this  country 
there  grew  up  in  the  neighborhood  of  several  of  these  springs  prosperous  communi- 
ties, the  permanent  population  in  which  had  a  common  purpose  in  the  exploitation 
of  their  springs,  to  the  end  that  a  thriving  trade  could  be  worked  up  with  strangers 
at  the  hands  of  the  population  and  of  learned  men  in  the  medical  profession.  From 
time  to  time  efforts  have  been  made  to  manufacture  some  of  these  "waters,"  and 
to  employ  them  at  the  patient's  home  rather  than  send  him  across  the  earth  to 
secure  their  benefits;  or  the  actual  waters  have  been  bottled  and  shipped  for  use, 
but  the  other  elements  of  treatment  have  been  usually  lacking  or  carried  out  half- 
heartedly, and,  therefore,  the  same  amount  of  good  has  not  come  about  in  most 
instances. 

But  in  all  these  localities  there  are  great  numbers  of  doctors,  and  patients  are 
given  not  only  the  waters,  but  more  or  less  careful  auxiliary  treatment,  and  usu- 
ally the  success  of  the  place  depends  even  to-day  on  the  adroitness  and  profes- 
sional skill  with  which  the  medical  practitioners  treat  their  patients  professionally 
in  other  ways  besides  the  waters. 

Upon  the  heels  of  the  "springs"  and  "baths"  finally  came  the  era  of  artificial- 
ity, in  which  nature  was  aped  by  mechanical  invention,  and  in  this  way  the  modern 
hydrotherapeutic  departments  in  institutional  work  came  into  effect.  Ordinary 
river  waters  were  treated  and  made  to  masquerade  as  mineral  spring  waters;  any 
temperatures  could  be  achieved;  calisthenics  and  athletics  could  be  employed;  diet 
could  be  regulated  as  in  the  watering-places  elsewhere. 

In  this  way  and  by  easy  stages  hydrotherapy  has  come  down  to  us  at  the 
present  time.  In  all  these  years  vast  experience  has  been  acquired,  and  it  seems 
that  we  are  just  now  on  the  eve  of  a  definite  parting  of  the  ways.  Charlatanism 
and  mental  therapy,  working  hand  in  hand,  are  choosing  a  ceremonious  magnifi- 
cence of  equipment,  much  mysterious,  sleight-of-hand  work  and  more  so-called 
"suggestion."  On  the  other  hand,  has  come  to  us  something  of  real  value  in  the 
hands  of  modern,  up-to-date,  and  honest  practitioners  of  internal  medicine,  and  with 
these  men  hydrotherapy  means  something  very  real. 

It  is  certain  that  very  many  disturbances  of  the  brain  anil  nervous  system  have 
their  origin  in  an  active  congestion  in  the  brain  and  its  membranes,  and  a  tre- 
mendous number  of  diseases  of  every  part  of  the  body  are  due  to  disturbances  of 
tile  circulation,  whereby  the  heart,  called  upon  to  do  more  than  its  normal  work, 
becomes  fatigued.  The  first  effort  of  nature  to  help  compensate  the  circulation 
results  in  an  increase  in  the  size  of  the  heart  muscle.  This  heart  dilatation.  QJ  per- 
trophy,  and  a  subsequent  dilatation  changes  the  relation  of  the  vessels  to  the  valves 
that  control  them,  and  we  get  what  we  call  heart  leaks  or  broken  compensation. 
In  this  condition  the-  heart  works  hard,  but  does  little, because  a  considerable  part 
of  the  blood  leaks  backward  and  is  not   driven   through   the  vessels  and   into   the 


394  OPERATION    OF    THE    HOSPITAL 

arteriovenous  stream  as  it  ought  to  be.  All  the  patient's  functional  organs  become 
clogged  because  too  much  blood  remains  in  them,  as  in  a  reservoir,  and  interferes 
with  their  functional  activities,  and  this  condition  is  expressed  by  a  pale,  waxy 
hue  of  the  face  and  cold,  clammy  skin  and  extremities  of  the  patient.  Under  these 
conditions  medical  heart  stimulants  have  about  the  same  effect  as  whipping  a  tired 
horse.  What  we  want  to  accomplish  in  these  cases  is  to  move  the  blood  in  the  easi- 
est possible  way,  and  with  the  least  work  of  the  heart,  away  from  the  great  central 
organs  of  the  body  and  out  into  the  muscles  and  skin  and  extremities.  And  we 
do  this  with  water  under  conditions  that  will  so  shock  the  nerve  ends  that  the 
arteries  and  capillaries  will  be  dilated  and  thus  invite  the  blood  stream,  rather  than 
by  remaining  contracted  repel  the  stream  and  dam  it  back  into  the  centers. 

The  Douche. — Experience  has  shown  that  the  best  way  to  bring  this  result 
about  is  to  employ  alternate  hot  and  cold  douches,  the  changes  being  made  so 
rapidly  that  the  temperature  of  the  body  cannot  possibly  be  raised  by  the  hot  douche 
or  lowered  to  the  point  of  chilling  by  the  cold  douche.  Anything  in  the  shape 
of  a  douche,  spray,  or  shower  will  bring  about  this  result,  provided  the  tempera- 
ture of  the  water  used  either  changes  rapidly  or  varies  greatly  from  the  temperature 
of  the  body. 

The  Nauheim. — Another  way  to  achieve  this  same  purpose  is  by  the  applica- 
tion of  either  chemic  or  physical  irritants  to  the  skin.  One  of  these  methods  we 
have  in  the  so-called  Nauheim  bath,  in  which  gas-bubbles  of  carbon  dioxid  are 
released  on  the  patient's  body  while  he  is  in  a  bath  at  about  or  just  a  little  below  the 
normal  body  temperature.  There  are  certain  chemic  bricks  which  when  dropped 
in  the  water  will  break  up  into  certain  constituent  elements,  releasing  carbon  di- 
oxid gas,  and  this  gas  rises  as  bubbles  from  the  bottom  of  the  tub,  attaches  itself 
to  the  patient's  body,  and,  because  it  is  lighter  than  water,  works  its  way  upward 
on  the  skin,  irritating  as  it  goes,  until  it  finally  bursts  into  the  atmosphere  at  the 
surface.  Perhaps  a  cleaner,  if  not  more  economic,  method  of  achieveng  the 
same  purpose  is  to  employ  tanks  of  carbon  dioxid  gas,  and  a  nickeled  coil  can  be 
made  to  circulate  the  bottom  of  the  bath-tub,  with  small  pinholes  at  f-inch  in- 
tervals along  its  length  to  release  the  gas  particles.  The  tank  is  connected  to 
this  coil,  and  the  gas  is  released  at  the  bottom  of  the  tub  after  the  tub  is  filled  with 
water  at  the  proper  temperature  and  the  patient  is  placed  in  it.  At  the  end  of 
ten  or  fifteen  minutes  of  this  sort  of  bath  the  patient  comes  out  with  the  body  and 
the  skin  and  surface  muscles  full  of  blood  drawn  away  from  the  great  central  organs, 
and  with  corresponding  relief  to  the  breathing  apparatus  and  the  heart's  work, 
because  an  immense  quantity  of  blood  has  been  coaxed,  as  it  were,  away  from  the 
centers  out  into  the  newly  dilated  peripheral  vessels. 

Another  way  of  bringing  about  the  same  result  is  by  rubbing  the  patient  with 
sea  salt  or  any  other  kind  of  salt,  or  with  any  more  or  less  irritating  substance,  im- 
mediately after  or  at  intervals  during  a  bath  in  common  water.  This  method  has 
the  disadvantage  of  applying  the  irritant  to  only  a  small  part  of  the  body  at  one 
time,  unless  the  rubbing  is  very  vigorous  and  takes  in  large  areas  of  the  surface,  and 
there  is  hardly  a  question  that  the  virtues  of  mineral  baths  and  salt  baths  of 
various  sorts  are  dependent  on  this  very  quality  of  irritating  the  skin  and  thus 
dilating  the  peripheral  vessels,  and  to  this  extent,  and  perhaps  to  this  extent  alone, 
the  mineral  waters  of  certain  springs  are  efficacious. 

Dry  or  Vapor  Heat. — There  is  another  way,  besides  those  mentioned,  of  increas- 
ing the  peripheral  circulation  of  the  blood,  and  in  that  way  emptying  the  great 
central  organs  of  their  superfluous  supply,  and  that  is  by  the  direct  application  to 
the  skin  of  vapor  or  dry  heat.     This  is  dene  in  the  so-called  cabinets,  or  sweat 


THK  DEPARTMENT  OF  HYDROTHERAPY  395 

baths,  or  "bakes,"  and  there  is  little  doubt  that  the  physiology  of  this  sort  of  heat 
action  is  twofold:  first,  it  has  an  irritant  action,  that  of  heat  itself,  and  thus  serves 

to  dilate  these  small  vessels;  and  the  second  action  is  the  sweat  process  of  withdraw- 
ing water  from  the  body,  and  is  a  physiologic  form  of  depletion  which  it  will  not 
be  necessary  for  us  to  go  into  in  more  detail;  the  main  point  is  that  the  process  brings 
about  an  increased  circulation  of  the  blood  away  from  the  great  central  organs  that 
have  been  so  clogged  that  they  have  been  unable  to  perform  their  functional  duties. 

A  good  many  medical  men  have  begun  to  use  the  "bake"  in  a  local  way  also 
in  cases  of  neuritis  or  rheumatism,  caused,  perhaps,  actively  by  the  presence  of  uric 
acid  or  other  toxic  matter,  which,  acting  as  a  direct  irritant  of  the  nerve  ends  in  the 
particular  locality  affected,  may  give  rise  to  the  pain  or  neuritis  or  rheumatism. 
The  "bake"  in  these  cases  performs  the  same  office,  but  in  another  way,  that  is, 
it  increases  the  circulation  of  the  blood  in  the  part  affected,  and  that  increased 
blood  activity  serves  to  carry  away  the  poisonous  matter  in  the  blood  stream  some- 
what in  the  same  way  that  a  great  rain  storm  flushes  the  sewers  and  cleans  out 
the  city. 

Passive  Resistance  Exercises. — Great  numbers  of  the  people  who  go  to  Europe 
to  the  baths  are  men  and  women  well  along  in  years,  who  have  lived  sedentary  lives 
or  who  have  dissipated  a  great  deal,  either-at  the  table  or  in  the  matter  of  alcoholic 
stimulants.  They  have  had  functional  disturbances  of  the  various  organs  of  the 
body  for  many  years,  but,  because  of  their  youth  and  strength  and  recuperative 
powers,  they  have  been  enabled  for  a  long  time  to  recover  from  these  periodic  or 
occasional  attacks,  brought  on  generally  by  some  special  overindulgence,  either  of 
work  or  dissipation.  But  finally  age  comes  along  as  a  side  issue  of  the  seizure,  and 
they  are  unable  to  "come  back,"  as  the  athletes  have  it.  If  they  are  financially 
able  to  do  so  they  are  ordered  by  their  physicians  to  travel  and  go  to  the  baths  of 
Germany  or  elsewhere,  and  there  they  place  themselves  under  the  rigid  discipline 
of  a  doctor,  and  are  ordinarily  helped  along  by  diet,  depletion  in  some  such  way  as 
we  have  outlined,  and  flushing  with  the  waters.  Eventually  there  comes  a  time 
when  these  artificial  agents  no  longer  serve  the  purpose.  The  heart  refuses  to  pick 
up  its  work  well,  the  blood  is  hardly  set  in  normal  motion  in  some  one  of  the  ways 
we  have  suggested  before  it  again  settles  into  the  centers,  and  the  heart,  like  a  great 
pump  with  too  small  a  suction-valve,  pounds  away,  accomplishing  little. 

We  must  resort  now  to  another,  a  subtler,  a  gentler,  and  a  less  shock-producing 
method  of  coaxing  the  blood  away  from  the  centers,  and  this  we  do  by  a  process 
the  best  known  form  of  which  is  Dr.  Schott's  passive  resistance  exercises.  There 
are  a  great  many  movements  in  these  exercises,  involving,  first  and  last,  nearly 
every  muscle  of  the  body.  It  will  not  be  profitable  for  us  to  go  into  detail  as  to 
these  movements.  They  are  treated  in  exhaustive  chapters  in  all  the  medical 
works  on  the  heart  and  circulation  and  metabolism.  Suffice  it  to  say  that  the 
muscles  of  the  body  are  moved  at  different  times  and  in  varying  degrees  of  activity 
against  an  almost  imperceptible  resistance  on  the  part  of  the  patient,  and  this 
gentle  work  of  the  muscles  calls  the  blood  away  from  the  central  organs  to  com- 
pensate for  the  waste  of  muscular  tissue  by  work,  the  difference  between  this  and 
the  former  methods  of  evening  up  the  circulation  being  that  this  particular  process 
has  for  its  object  a  more  lasting  result.  These  movements  are  made  to  take  up  a 
great  deal  of  time,  beginning  with  perhaps  five-  or  ten-minute  periods  and  increas- 
ing from  day  to  day  until  a  half-hour  can  be  devoted  to  the  work,  and  eventually  a 
considerable  amount  of  exercise  can  be  gained  without  overworking  the  heart,  as 
would  be  the  case  if  it  were  active  exercise  performed  by  the  patient  himself. 

Many  patients,  old  men  and  old  women,  come  for  treatment  with  heart  beating 


396  OPEEATION    OF   THE    HOSPITAL 

at  125  per  mintue,  in  a  flabbly,  sluggish  sort  of  way,  and  at  the  end  of  the  day's 
treatment  with  these  passive  resistance  exercises  the  heart  will  have  subsided  to 
90  or  even  80,  and  its  beat  will  have  taken  on  a  better  tone  and  will  have  become 
more  productive  of  results.  At  first  this  improvement  will  last  for  only  a  short 
time,  but  after  a  while  the  improvement  will  continue  for  many  hours,  and  event- 
ually the  heart  will  have  settled  down  regularly  to  the  profitable  employment  of 
getting  the  blood  stream  through  all  parts  of  the  body. 

Massage. — Massage  is  a  somewhat  different  thing,  but  it  is  proper  that  massage 
should  be  done  in  connection  with  a  department  of  hydrotherapy  because  its  ulte- 
rior purpose  is  along  the  same  general  line.  Massage  of  a  muscle,  no  matter  which 
muscle,  is  the  working  of  that  muscle  involuntarily,  so  far  as  the  patient  is  con- 
cerned. It  is  passive  motion  again,  and  the  kneading  process  employed  in  massage 
calls  the  blood  supply  to  the  part,  stimulates  metabolism,  and  not  only  improves 
the  quality  of  the  muscle  and  increases  its  usefulness,  but  it  likewise  withdraws  from 
the  centers  the  additional  amount  of  blood  necessary  in  the  performance  of  the 
muscle  work,  and  thus  helps  in  a  small  way  to  relieve  the  clogging  of  the  centers. 

But  massage  has  another  purpose.  Generally  speaking,  in  those  who  are  proper 
subjects  for  general  massage  there  is  a  great  deal  of  unemployed  fat  in  the  tissues. 
No  voluntary  movements  of  the  patient  will  serve  to  increase  the  blood  supply 
in  that  fatty  tissue,  and  hence,  after  a  while,  we  have  a  condition  in  the  fatty  tis- 
sues of  the  body  that  might  be  likened  to  a  swamp  where  water  stands  and  where 
nothing  happens,  either  in  the  water  or  in  the  soil.  The  whole  area  becomes  waste 
and  worthless  and  unproductive.  But  the  waste  isn't  carried  away  because  there  is 
no  running  water — or  no  flowing  blood.  To  relieve  this  condition  we  must  bring 
in  some  artificial  stimulation  to  increase  the  blood  supply,  to  carry  away  the  waste- 
products,  and  to  release  the  constituents  of  the  fats  out  into  the  blood  stream  that 
has  been  brought  there,  and  so  get  rid  of  the  whole  marsh.  Therefore,  we  pinch 
and  knead  and  punch  the  area.  We  "insult"  the  locality,  as  the  physician  says, 
and  blood  rushes  in  as  nature's  way  of  coming  to  the  rescue,  and  in  this  way  we 
flush  out  these  fatty  areas  and  carry  the  waste  away. 

Having  now  considered  some  of  the  uses  of  water  in  the  treatment  of  disease 
and  the  ulterior  motives  behind  its  employment,  we  have  to  consider  the  apparatus 
necessary  in  the  equipment  of  such  a  station  in  an  institution. 

For  the  small  institution  with  small  funds  and  perhaps  little  room  much  may 
be  done  with  very  little  apparatus,  and  that  of  inexpensive  design,  such  as  a  large 
tub  for  plain  or  medicated  baths,  and  in  which  an  excellent  Nauheim  may  be  given 
by  the  use  of  the  chemic  carbonic  acid  gas  bricks,  and  which  may  be  used  also  to 
give  sea  or  other  salt  rubs  or  so-called  "glows." 

A  shower,  with  plumbing  so  arranged  that  it  may  be  quickly  changeable  from 
hot  to  cold  and  vice  versa. 

A  sweat  cabinet  can  be  home  made:  merely  a  tight  box  with  a  hole  in  the 
top  for  the  head,  and  with  a  few  steam  coils  inside,  arranged  behind  a  grating  so  the 
patient  cannot  touch  them;  a  long  thermometer  protruding  from  the  inside,  so  that 
it  may  be  easily  read  by  the  attendant.  If  an  "arm-bake"  and  "leg-bake"  are  de- 
sired, these  can  be  made  with  sliding  panels  in  the  sides  for  the  arms,  and  with  panel 
section  in  the  front  for  one  or  both  legs,  on  the  principle  of  the  old-fashioned 
prison  stocks. 

A  strong,  narrow  table  3  feet  instead  of  30  inches  high  for  purposes  of  massage. 

This  simple  equipment  can  all  be  installed  in  one  large  room,  and,  if  parti- 
tions made  with  canvas  hung  on  nickeled  tubing  are  used,  a  single  operator  may  care 
for  two  or  more  patients  at  a  time — one  in  the  cabinet,  one  in  the  tub,  and  a  third 


Till'.    DEPARTMENT    OF    II VDItOTIIKHAPY 


397 


hands  on  the  massage  table.     Fig.  115  shows  this  arrange- 


by  canvas 
few  chairs 


under  tl perator': 

iiicnt  very  well. 

There  ought  to  be  a  second  room  with  rest  couches,  separated  also 
1  >ar1  i  I  i<  >ns.     A  few  1<  ickers  for  patients'  clothing  and  the  bath-robes  and  a 
will   complete  an  unpretentious  but  very  ser- 
viceable equipment. 

For  the  large  general  hospital,  the  insane 
asylum,  or  the  pretentious  sanatorium,  where 
a  more  elaborate  equipment  is  desired,  there 
should  be  at  least  three  rooms,  the  most  im- 
portant of  which  is  the  douche  room,  because 
here  must  he  installed  the  douches,  needle 
sprays,  showers,  and  the  salt  baths.  Fig.  146 
shows  an  assemblage  of  these  devices.  The 
difficult  essentials  for  success  in  this  room 
are  (1)  a  properly  constructed  control  table, 

(2)  a  lead  basin  at  least  a  foot  deep  over  the 
whole  floor,  with  drain  and  slatted  floor,  and 

(3)  properly  constructed  walls  that  will  with- 
stand steam  vapor  and  hot  and  cold  water. 

Control  Table. — It  will  be  rather  super- 
fluous to  go  into  a  description  of  a  control 
table,  because  the  makes  of  the  different 
manufacturers  are  practically  alike.  The 
tables  are  usually  made  of  marble,  with 
nickeled  finishings.  There  is  a  mixing  cham- 
ber on  each  side  in  the  interior,  and  these  lead 
to  the  various  sorts  of  outlets — that  is,  the 
douches,  needle  spray,  shower,  and  the  various 
sorts  of  baths.  Some  of  the  tables  have  an 
ice-water  connection,  besides  the  usual  hot 
and  cold,  hut  most  of  us  find  this  ice  water 
wholly  superfluous,  excepting  perhaps  in  the 
hot  climate  of  the  South,  and  even  there  there 
is  usually  a  great  enough  difference  between 
the  hot  and  cold  water  to  obtain  all  the  shock 
necessary  to  the  system.  The  temperature 
of  the  water  is  regulated  through  the  mixing 
chambers  by  sliding  valves  operating  on  regu- 
lating  levers  in  the  face  of  the  apparatus. 
There  is  a  douche  spout  coming  from  each 
mixing  chamber — that  is,  one  on  each  side  of 
the  apparatus— and  it  is  from  these  we  obtain 
the  alternating  hot  and  cold  douche.  There 
are  two  thermometers,  one  on  each  side  of 
the  apparatus,  and  each  one  connected  with 
its  mixing  chamber,  for  indicating  the  tem- 
perature of  the  water  as  it  passes  through  the  chamber.  In  some  of  the  newer 
tables   there  are   also   two   electric    t  herinomelers.   the    temperature   device   resting 

in  (he  mixing  chambers,  and  the  electric  controls  operating  a  bell,  through  an 

ordinary  dry  cell  battery:  this  electric  mechanism  is  used  as  a  thermostat  and  as 


398 


OPERATION    OF    THE    HOSPITAL 


an  alarm,  to  indicate  the  maximum  and  minimum  heat  and  cold  points  for  the 
protection  of  the  patient. 

The  details  of  the  control  table  are  so  nearly  alike  in  all  the  makes  of  apparatus 
that  the  differences  of  mechanism  between  the  various  varieties  need  not  greatly 
concern  the  hospital  administrator  who  proposes  to  purchase  an  apparatus,  and 
his  chief  anxiety  must  be  directed  to  obtaining  a  mechanism  of  installation  that 
can  be  absolutely  depended  on  in  the  matter  of  temperatures.  All  the  makers 
of  this  control  table  claim  exceptional  devices  for  controlling  the  temperatures 
to  the  smallest  fraction  of  a  degree,  but  it  is  the  experience  of  most  of  us  that 
none  of  them  live  up  to  the  claims  made  for  them,  and  there  seems  to  be  only 
one  method  by  which  the  temperatures  of  the  water  in  the  two  sides  of  the  con- 
trol table  can  be  maintained  over  any  considerable  length  of  time,  and  that  is  by 
arrangement  of  the  plumbing  outside  the  table  itself.  Where  the  control  table  is 
fed  from  a  common  circulating  system  it  is  impossible  to  control  the  temperatures. 


Fig.  146. — The  water-room  of  the  department. 

For  instance,  we  may  desire  a  temperature  on  one  side  of  the  table  of  105°  F.,  and 
we  manipulate  the  temperature  lever  until  we  fix  that  temperature  definitely  by 
the  introduction  of  hot  and  cold  water  into  the  mixing  chamber  on  that  side; 
but  presently  the  faucets  at  some  remote  point  in  the  circulation  of  the  cold  water 
are  turned  on,  which  has  the  effect  of  immediately  dropping  the  pressure  all  along 
the  line,  including  the  mixing  chamber,  and,  therefore,  the  relative  pressure  of  the 
hot  and  cold  water  are  changed.  More  hot  water  rushes  in  because  the  cold  water 
pressure  is  reduced,  and  the  temperature  runs  up  so  rapidly  in  some  cases  as  to  burn 
the  patient  before  the  alarm  is  given,  and  the  contrary  may  also  occur,  that  is, 
the  hot  water  may  be  drawn  upon  and  the  pressure  reduced,  allowing  a  greater 
amount  of  cold  water  to  rush  in  and  the  temperature  is  lowered  rapidly. 

In  a  great  many  instances  the  alternating  hot  and  cold  douche,  in  fact,  any  of 
the  various  forms  of  control  table  therapy,  are  used  in  connection  with  nervous 
patients,  and  such  a  patient  is  not  likely  to  be  improved  if  the  water  in  the  bath  is 


THE    DEPARTMENT   OF  HYDROTHERAPY  399 

allowed  to  jump  almost  instantly  from  body  heat  (98.6°  F.)  up  to  120°  or  130°  F.,  or 
from  body  heat  down  to  55°  or  65°  F.,  and  oftentimes  great  harm  is  done  by  fright 
to  the  individual  and  a  shock  to  the  system,  and  any  good  that  could  possibly  be 
accomplished  by  the  use  of  the  apparatus  is  destroyed.  So  important  is  this  tem- 
perature regulation  that  we  should  go  clear  back  to  the  power-house  for  our  supply, 
from  which  the  pressure  will  always  be  the  same.  It  will  be  all  the  better  for  the 
regulating  effect  if  the  hot-  and  cold-water  pipes  can  come  directly  off  the  power- 
plant  reservoir,  and  are  entirely  independent  of  any  circulation  pipes  whatsoever. 

Needle  Spray  and  Shower. — This  device  is  not  only  a  very  popular,  but  a  most 
efficient  method  of  employing  water  in  the  treatment  of  disease.  There  are  four 
columns  of  tubing,  rising  square-like,  each  equally  distant  from  the  other,  with  the 
pipes  bent  to  converge  at  6  or  7  feet  from  the  floor.  Beginning  knee  high,  and 
at  intervals  of  6  or  8  inches,  there  are  3|-inch  rose  sprays  leading  from  each  point 
for  the  needle  spray  and  there  is  a  shower  at  the  top.  The  rose  sprays  are  set  in 
ball-bearing  joints,  permitting  a  free  movement  to  fix  the  direction  of  the  small 
streams. 

While  all  the  manufacturers  of  control  tables  are  making  sincere  and  serious 
and  progressively  successful  efforts  to  improve  their  devices,  it  seems  that  the  J. 
L.  Mott  Co.,  of  New  York,  has,  up  to  the  present  time,  given  the  matter  more  atten- 
tion than  others,  and  has  produced  a  mechanism  of  better  workmanship  and  of  more 
perfectly  working  parts  than  others,  and  capable  of  a  more  certain  control. 

We  show  in  Fig.  145  a  very  well  designed  hydrotherapeutic  suite  that  may  be 
elaborated  or  contracted  to  conform  to  any  special  conditions  desired. 


THE  HOSPITAL  PHARMACY 

Equipment  of  the  Drug  Store. — The  question  of  drugs  naturally  is  not  nearly 
so  important  as  it  was  a  few  years  ago;  indeed,  there  are  many  physicians  and 
surgeons,  especially  the  latter,  who  confine  their  medical  prescriptions  almost 
exclusively  to  an  occasional  placebo  or  to  a  quieting  potion  following  some  severe 
surgical  procedure.  In  the  medical  department  many  of  the  foremost  practitioners, 
having  turned  their  attention  to  metabolism  and  to  the  modern  view-point  of  the 
nature,  etiology,  and  cure  of  disease,  rely  almost  wholly  upon  the  dietary  for  their 
results,  with  such  aids  as  they  may  receive  from  a  careful  direction  of  the  habits, 
rest,  and  exercise  of  the  patient,  and  some  form  of  mental  suggestion.  In  the 
maternity  department  medicines  are  very  little  used,  with  the  exception  of  an  occa- 
sional aperient  or  some  outward  application  in  the  case  of  the  mother,  and,  so  far 
as  the  baby  is  concerned,  if  the  institution  could  be  entirely  free  from  medicine 
of  every  sort  the  newborn  baby  would  probably  fare  better. 

In  the  children's  department  diet  has  come  to  take  the  place  almost  exclu- 
sively of  the  medication  of  a  former  day.  Milk  and  milk  formulae,  cereals,  and  soft 
diets  generally  are  the  treatment  that  are  relied  on  almost  exclusively  by  the 
modern  pediatrician.  Again,  the  great  drug  houses  and  chemical  manufactories 
are  compounding  tablets,  pills,  and  quasi-proprietary  medicines  of  such  accurate 
value  that  the  former  necessity  to  make  up  these  prescriptions  in  the  pharmacy 
of  the  institution  no  longer  exists. 

And  yet  every  hospital  and  similar  institution  must  have  a  drug  supply  and  a 
place  in  which  to  dispense  the  drugs,  and  a  few  pertinent  questions  arise  concern- 
ing the  equipment  and  conduct  of  this  necessary  feature. 

Where  in  the  institution  shall  the  drug  store  be?  Shall  the  medicines  be  dis- 
pensed directly  to  the  patients  from  the  main  drug  store  or  from  auxiliary  medicine 
cabinets  on  the  floors?  What  fixtures  shall  be  used  in  the  drug  store — what  kind 
of  medicine  containers?  What  kind  of  labels  shall  be  used  in  the  drug  store  and 
in  the  medicine  cabinets  on  the  floors?  What  shall  be  the  extent  of  the  drug  supply? 
Must  large  quantities  of  medicines  be  bought  and  kept,  or  small?  If  medicines  are 
kept  in  cabinets  on  the  floors  and  adjacent  to  the  wards,  must  these  auxiliary  sup- 
plies be  large  or  small  in  variety?  These  are  some  of  the  questions  that  present 
themselves. 

Without  much  reference  to  the  order  in  which  these  questions  have  come  up, 
let  us  discuss  them  briefly.  In  the  first  place,  the  generosity  of  the  drug  supply 
will  depend  on  a  number  of  things,  as,  for  instance,  the  character  of  the  institu- 
tion, the  kind  and  variety  of  its  work.  If  there  are  a  great  number  of  departments, 
or  especially  if  there  are  a  great  number  of  medical  men  attending  the  institution, 
it  will  be  necessary  to  carry  a  considerable  chug  stock,  because  it  is  almost  impossible 
to  get  medical  men  to  agree  on  the  -dosage  and  forms  of  medicine  they  are  to  use. 
This  question  is  vastly  simplified  if  the  institution  is  a  public  one,  where  there  is 
a  good  deal  of  sameness  in  the  character  of  the  diseases  treated.  Sometimes  in 
such  a  case  a  few  formulae  can  be  employed,  and  the  whole  medication  of  the  insti- 
tution confined  ■within  the  bounds  of  a  dozen  prescriptions,  put  up  in  large  quanti- 
ties, and  dispensed  by  numbers  on  the  bottles.     It  is  not  the  staple  medicines  that 

400 


THE    HOSPITAL    PHARMACY  401 

cost  the  money  in  the  institution  drug  store  of  to-day;  it  is  the  vast  variety  of  pro- 
prietary medicines  that  must  be  bought  for  individual  cases  to  please  the  doctor 
who  has  a  private  patient  on  his  hands.  Oftentimes  we  must  pay  seventy-five 
ciiits  or  a  dollar,  sometimes  four  or  five  times  that  amount,  for  a  sealed  package 
out  of  which  one  or  a  very  few  doses  are  used.  And  this  question  of  whether  a 
large  or  small  stock  of  drugs  must  be  kept  is  dependent  very  much  on  the  loca- 
tion of  the  institution.  If  it  is  in  a  large  city  or  near  a  wholesale  drug  house,  where 
an  emergency  medicine  can  be  had  quickly,  the  variety  of  the  stock  necessary  to  be 
kept  will  be  very  greatly  simplified.  There  is  the  ethical  question  also  that  must 
lie  settled  before  we  can  undertake  to  determine  the  extent  of  the  stock  to  be  kept, 
ami  it  is  whether  or  not  the  attending  physicians  in  the  institution  shall  be  allowed 
to  have  entire  freedom  in  their  prescription  writing.  A  physician  can  almost 
break  up  an  institution,  if  he  has  considerable  practice  there,  and  allows  his  fancy 
to  run  riot  in  the  way  of  medicines.  On  the  other  hand,  who  shall  say  whether 
the  ingredients  in  a  given  prescription  are  simply  a  fad  on  the  part  of  the  doctor 
or  are  actually  necessary  to  the  well  being  of  the  patient?  Just  here  there  seems 
to  be  the  greatest  possible  need  that  the  medical  staff  shall  work  in  harmony  with 
the  necessities  of  institution  economies,  and  where  this  harmony  exists  there  will 
hardly  come  a  question  as  to  whether  or  not  the  doctor  may  have  the  medicines  he 
prescribes. 

Then  the  next  question  is,  What  quantities  of  a  staple  medicine,  such  as  glycerin, 
quinin,  carbolic  acid,  castor  oil,  linseed  oil,  flaxseed  meal,  and  the  like,  are  to  be 
kept?  There  are  two  phases  of  this  question.  The  first  concerns  the  keeping  qual- 
ity of  the  medicines.  If,  for  instance,  it  is  glycerin,  that  can  be  very  well  kept 
if  propery  contained;  one  may  lay  in  a  large  supply  occasionally.  There  are  other 
medicines,  however,  that  must  be  purchased  in  very  small  quantities,  as  needed, 
such,  for  instance,  as  hydrocyanic  acid,  apomorphin,  and  all  its  salts  and  prepara- 
tions, and  nitrate  of  silver,  crystals  or  molded.  There  will  often  come  an  occasion 
such  as  this — a  physician  will  prescribe  half  a  dram  of  a  certain  medicine  that  must 
be  bought  in  a  sealed  package  costing,  say,  $5  a  pound,  and  it  will  be  necessary  to 
purchase  the  whole  package  or  to  pay  25  cents  for  a  dram.  The  question  comes  up 
which  is  the  more  economic.  Undoubtedly,  if  the  medicine  is  one  which  is  very 
rarely  employed,  or  likely  to  spoil  in  keeping,  it  will  be  more  economic  to  pay  25 
cents  for  the  amount  actually  required  than  to  buy  a  whole  unbroken  package, 
which  may  never  be  used  again  or  kept  beyond  its  keeping  power  before  it  is  called 
for. 

(  M'tentimes  the  druggist  of  the  institution  will  be  warned  by  his  wholesale  house 
that  a  certain  article  is  going  to  presently  advance,  as,  for  instance,  when  the  law- 
went  into  effect  in  this  country  prohibiting  the  adulteration  of  glycerin,  immedi- 
ately the  price  of  glycerin  almost  doubled.  Many  institution  pharmacists  take 
ai  [vantage  of  the  certainty  of  the  advance  in  price  and  lay  in  a  large  supply.  There 
will  frequently  be  like  periods  in  regard  to  other  drugs,  and  the  institution  will 
have  an  opportunity  to  lay  in  a  large  supply  at  sometimes  one-half  the  price  they 
would  have  to  pay  a  little  later.  If  it  is  a  drug  that  will  keep  well,  of  course  it  will 
pay  to  lay  in  the  larger  amount. 

These  main  thoughts  will  probably  suffice  as  to  the  drug  supply  itself.  Let  us 
now  consider  the  fixtures  in  the  drug  store.  Glass  and  metal  and  marble  make 
beautiful  fixtures  for  a  drug  store,  and  if  they  be  supplemented  with  a  white  tiled 
floor  we  have  a  most  attractive  room.  But,  in  the  interest  of  the  greatest  useful- 
ness, we  must  forego  the  question  of  ornamentation  that  would  be  secured  in  these 
pretty  fixtures.       A  drug  store  is  a  place  of  bottles,  and  bottles  break  easily  when 


402  OPERATION    OF  THE    HOSPITAL 

coming  in  violent  contact  with  metal  or  marble  or  other  glass,  and  it  may  be 
questioned  whether  the  clean  look  of  this  metal  and  marble  furnished  drug  store  is 
actual  or  apparent.  There  is  no  doubt  that  many  acids  stain  marbles  and  corrode 
metals,  and  it  will  not  be  very  long  before  the  drug  store  that  started  out  so  beau- 
tiful will  be  a  place  of  spots  and  stains,  and,  where  glass  shelving  and  marble  tables 
are  employed,  the  metal  screws  and  rivets  and  other  fastenings  will  loosen  eventually, 
especially  those  parts  that  come  in  jarring  distance  of  the  work  counter,  where  the 
mortar  and  pestle  are  used  and  where  unguents  are  rubbed  up.  On  the  other 
hand,  well-seasoned,  substantial  wood  fixtures,  well  painted  and  varnished,  will 
keep  in  good  order  for  a  long  time,  and  they  can  then  be  repainted  and  revarnished 
to  make  them  as  good  as  new,  and  there  are  very  few  medicines  and  even  acids 
that  damage  wood  as  much  as  they  do  metal  and  marble,  so  that  wooden  fixtures 
in  a  drug  store,  and  even  the  tops  of  the  work  tables  and  counters,  will  last  longer 
and  look  better  if  made  of  birch  or  maple.  And  the  same  will  be  true  of  the  floor- 
ing; tile  is  very  pretty  when  new,  but  is  easily  stained  by  certain  drugs,  and  the 
expensiveness  of  a  concrete  floor  is  not  told  in  its  first  cost,  but  rather  in  the  tre- 
mendous breakage,  due  to  falling  bottles,  glass  stoppers,  glass  utensils,  and  the 
like. 

The  next  question  that  will  present  itself  is  the  labels  for  the  bottles,  not  only 
for  the  drug  store,  but  for  the  medicine  cabinets  on  the  floors.  This  looks  to  be 
rather  a  trivial  matter,  but  frequently  the  cost  of  labeling  the  bottles  in  an  insti- 
tution runs  up  into  many  hundreds  of  dollars  if  the  work  is  done  in  a  permanent 
and  attractive  manner. 

Ground  stoppered  glass  bottles,  with  etched  or  glass  labels,  and  properly  labeled 
ointment  pots  cost  on  an  average  about  40  cents  each,  or,  for  the  hundred  articles 
that  go  into  each  floor  cabinet,  about  $60.  In  some  hospitals  gum  labels  with 
paraffin  covering  are  used,  or  even  the  plain  gummed  labels,  without  any  protective 
covering  at  all.  For  laboratories,  or  when  only  one  or  two  careful,  scientific  men  are 
to  handle  them,  this  may  be  sufficient,  untidy  as  it  is,  but  where  bottles  must  be 
handled  by  undergraduate  nurses  who  change  frequently,  and  when  a  mistake  in 
the  reading  of  a  blurred  label  may  spell  the  death  of  a  patient,  it  will  not  do  at  all. 

The  next  question  that  will  arise  concerns  the  dispensing  of  medicines  to  the 
patients;  that  is,  the  character  and  location  of  auxiliary  medicine  cabinets  about  the 
institution.  Some  few  years  ago  a  hospital  architect  somewhere  designed  a  medi- 
cine cabinet  that  was  most  attractive.  It  was  made  of  metal,  set  into  the  wall  at  a 
convenient  location  near  the  ward,  or  in  some  instances  in  the  ward,  and  was  made 
up  of  two  compartments,  with  a  marble  slab  30  inches  from  the  floor  as  the  bot- 
tom of  the  cabinet;  and  the  upper  part  was  divided  into  two  sections,  one  large, 
to  contain  the  great  bulk  of  the  commoner  medicines,  and  a  small  compartment 
with  a  separate  door.  The  shelves  in  the  cabinet  were  nearly  a  foot  deep,  and  a 
great  many  medicines  could  be  carried  in  the  cabinet  by  setting  the  bottles  several 
rows  deep.  The  attractive  feature  of  the  whole  arrangement  was  the  lighting 
scheme.  The  small  cabinet  inside  the  larger  one  was  supposed  to  contain  alkaloids 
and  poisons  generally,  and  a  red  light,  supposed  to  be  the  danger  signal,  was  turned 
on  automatically  when  the  door  was  opened.  A  white  light  was  turned  on  auto- 
matically when  the  double  doors  of  the  main  cabinet  were  opened. 

The  marble  slab  at  the  bottom  of  the  cabinet  had  a  basin  and  faucet  about  the 
middle  of  it,  with  hot  and  cold  water.  The  whole  arrangement  looked  most  attract- 
ive, and  was  one  of  the  most  deceptive  things  imaginable.  The  presence  of  the 
red  light  indicated,  in  the  first  place,  that  there  was  need  of  warning  somebody 
presumably  ignorant  of  the  character  of  the  drugs  kept  in  the  case,  and  the  genius 


THE   HOSPITAL   PHARMACY 


103 


who  designed  the  apparatus  probably  expected  patients  to  go  there  and  help  them- 
selves to  medicines.  The  depth  of  the  cabinet,  providing  for  several  bottles  dec]). 
made  the  whole  thing  unusable,  because,  as  a  rule,  nurses  who  want  medicines 
cannot  take  the  time  to  remove  half  a  dozen  bottles  before  they  get  the  one  they 
want,  and,  as  a  rule,  the  nurses  will  not  even  take  the  time  to  see  if  the  medicines 
arc  in  the  cabinet;  they  will  order  new  ones  from  the  main  drug  supply,  so  that  it 
can  well  happen  that  there  will  be  three  or  four  different  bottles  of  a  certain  medi- 


Fig.  147. — Medicine  case. 


cine  in  the  cabinet  at  the  same  time.  The  glass  shelves  of  the  cabinet  reached  out 
to  the  miter  edge  of  the  marble  slab,  placed  there  for   the  purpose  of  being  Used  as 

a  work  table  to  hold  the  medicine  trays,  and  the  fact  that  these  shelves  project 
over  so  far  makes  the  marble  slab  unavailable  for  use.  Fig.  1  17  shows  a  different 
sort  of  medicine  cabinet.  This  cabinet  was  designed  for  the  Michael  llee-e  Hos- 
pital. The  illustration  is  good  enough  to  show  all  the  details  of  the  cabinet,  and 
it  will,  therefore,  need  no  description.      The  only  lighl   in  the  cabinet,  and  the  oiil\ 


404  OPERATION   OF  THE   HOSPITAL 

light  needed,  is  a  white  light  set  into  the  top.  The  shelves  are  4  inches  deep,  and 
will  hold  only  one  bottle  in  depth.  The  sink  and  basin  are  off  to  one  side  of  the 
marble  work  slab,  and  the  slab  is  16  inches  deep,  leaving  plenty  of  space  to  set  the 
medicine  trays.  The  space  under  the  work  slab  is  made  up  of  shelves  on  one  side 
and  a  cupboard  on  the  other.  This  cabinet  has  been  adopted  in  a  large  number  of 
hospitals,  and  it  is  giving  perfect  satisfaction. 

We  may  go  out  of  our  way  here  just  long  enough  to  suggest  that  these  medicine 
cabinets  should  never  be  in  the  wards,  except  in  children's  hospitals  or  wards,  in 
which  case  it  is  necessary  for  the  nurse  to  be  always  in  sight  of  the  patients;  then 
the  cabinet  should  be  kept  locked  or  closed  with  an  automatic  fastener.  Many 
of  us  can  remember  the  time  when  each  patient's  medicine  was  kept  on  a  small 
table  at  his  bedside,  and  he  was  expected  to  take  his  medicine  without  bothering 
the  nurse  about  it.  This  will  not  do  any  longer,  because  patients  are  wholly  irre- 
sponsible regarding  their  own  necessities;  therefore,  in  every  well-regulated  insti- 
tution there  are  medicine  nurses,  and  patients  are  never  permitted  to  handle  either 
their  own  or  other  patients'  medicines;  indeed,  many  patients  have  committeed 
suicide  by  the  ease  with  which  they  could  get  poisonous  medicines,  and  many 
patients  have  lost  their  lives  through  the  irresponsibility  of  other  patients  who 
undertook  to  dose  out  the  medicine  to  them.  If  it  is  a  very  small  hospital,  or  a  very 
small  floor  or  ward,  it  will  not  take  very  long  for  the  nurse  to  get  round  periodically 
to  give  patients  their  medicines,  and,  if  it  is  a  large  area  to  be  covered  and  a  large 
number  of  patients  to  be  served,  there  ought  to  be  a  nurse  charged  with  the  respon- 
sibility and  detailed  for  the  purpose  of  giving  medicines.  There  is  a  good  deal  to 
be  said  on  the  question  of  the  location  of  medicine  cabinets,  the  responsibility 
resting  upon  the  hospital  in  the  matter  of  giving  medicines  to  patients,  and  the 
care  and  technic  with  which  medicines  should  be  given. 

Modern  medicine  has  brought  into  use  many  serums,  antitoxins,  and  vaccines, 
and  these  things  need  to  be  kept  at  certain  low  but  regular  temperatures  if  they  are 
to  be  relied  upon,  and  this  makes  it  necessary  to  have  an  accurately  controlled 
refrigerator  in  or  very  near  the  drug  room.  If  the  temperature  is  permitted  to  run 
too  low  these  biologic  preparations  will  be  destroyed,  and  if  it  is  allowed  to  go  too 
high  they  will  be  destroyed  even  more  quickly;  about  40°  F.  is  usually  considered 
the  best  temperature,  but  it  must  not  be  allowed  to  vary.  In  large  institutions 
these  goods  may  be  kept  in  the  refrigerators  of  the  laboratory  of  pathology,  but  they 
are  better  kept  with  the  drug  supply,  so  they  will  not  be  likely  to  be  mistaken  for 
other  things  in  the  laboratory  refrigerator  not  intended  for  patients. 


HOSPITAL  DIETETICS 

There  are,  or  should  be,  three  chemists'  shops  in  every  hospital.  One  is  the 
drug  store,  in  which  prescriptions  for  medicine  are  compounded;  the  second  is  the 
milk  laboratory,  in  which  prescriptions  for  milk  arc  compounded,  especially  for 
sick  children;  and  the  third  is  the  diet  kitchen. 

Of  these  three,  undoubtedly  the  department  of  dietetics  is  the  most  important, 
because  medicines  are  becoming  less  a  factor  in  the  care  of  the  sick,  and,  in  any 
event,  their  preparation  is  a  thoroughly  settled  profession;  and,  in  a  final  analysis 
the  sick  children  could  be  fed  on  mothers'  milk,  or  pure  fresh  cows'  milk,  or  the 
milk  of  some  other  animal,  like  the  goat.  But  the  dietary  for  the  adult  has  become 
of  vast  importance  in  the  treatment  of  disease,  and  many  of  the  great  medical  men 
of  the  day  are  almost  confining  themselves  in  the  treatment  of  disease  to  physical 
and  dietetic  therapy. 

It  is  no  concern  of  the  hospital  administrator  what  diet  is  prescribed,  but  it  does 
concern  him  that  the  doctor  shall  have  for  his  patient  precisely  what  he  orders  in 
the  way  of  a  diet. 

In  nearly  all  institutions  there  are  prescribed  diets,  as,  for  instance,  a  non- 
nitrogenous  diet,  a  diabetic  diet,  a  salt-free  diet,  and  so  on,  and  these  printed  diet 
lists  are  usually  hung  in  conspicuous  places  in  the  kitchens  and  serving  rooms,  and 
every  patient  in  the  institution  will  be  fed  according  to  one  or  the  other  of  them. 

The  unfortunate  thing  about  our  attempts  to  administer  an  efficient  dietary  in 
an  institution  is  that  the  principles  of  biology  and  physiology  and  the  science  of 
dietetics  are  themselves  in  an  evolutionary  stage,  and  the  doctors  do  not  agree; 
and,  still  more  unfortunately,  some  of  the  doctors  when  they  prescribe,  for  in- 
stance, a  non-nitrogenous  diet,  expect  the  patient  to  be  fed  on  food  that  con- 
tains no  nitrogen;  manifestly,  this  is  impossible,  because  all  food  materials  con- 
tain nitrogen  or  the  making  of  nitrogen.  These  same  doctors  who  prescribe  a 
diabetic  diet  expect  their  patients  to  have  a  diet  entirely  free  from  sugar;  this, 
again,  is  impossible,  because  all  diets  contain  sugar  or  some  sugar-former  to  a  cer- 
tain extent.  The  diet  lists  of  all  hospitals,  therefore,  are  merely  relative,  and  arc 
confined  to  such  articles  of  food  as  contain  a  minimum  of  the  interdicted  constituent, 
whatever  ttiat  may  be.  Furthermore,  the  manner  of  preparation  of  foods  plays  an 
important  part  in  the  availability  of  their  nutritive  constituents — that  is  to  say. 
in  the  cooking  of  meats  the  temperature  may  be  brought  to  so  high  a  point  that 
the  proteins  will  be  coagulated  past  the  possibility  of  breaking  up,  and  will  thus 
be  lost  as  an  available  nutriment;  the  carbohydrates  may  not  lie  sufficiently  cooked 
to  soften  the  intercellular  tissue,  so  that  the  digestive  agents  can  reach  the  actual 
value  within  to  make  that  available.  Again,  new  choline  compounds  are  some- 
times formed  in  the  processes  of  cooking,  and  these  may  be  important  factors  to 
aid  or  retard  digestion.  So  it  will  not  do  to  prescribe  foods  taking  their  chemic 
ratios  for  granted,  as  we  do  in  medicines  from  the  pharmacy;  we  must  look  veiy 
much  further  ahead,  to  determine  not  only  what  the  particular  food  is,  but  all  its 
chemic  and  physiologic  value. 

It  is  a  peculiar  fact   that,  while  medical  science  has  progressed  tremendously  in 

the  fields  of  metabolism,  and  has  reversed  many  beliefs  of  a  former  day.  we  still 
employ  those  sacred  diet  lists  that  were  revered  twenty  years  ago.     No1  only  that, 


406  OPERATION   OF   THE   HOSPITAL 

while  the  laboratory  of  to-day  has  placed  on  record  a  distinct  recognition  of  vast 
differences  between  individuals  in  the  matter  of  food  assimilability,  we,  in  the 
clinics,  go  along  prescribing  three  or  four  diets,  as  though  all  individuals  were  alike, 
and  there  were  only  three  or  four  diseases  in  the  world.  In  a  fortunately  long- 
forgotten  day  every  hospital  had  its  half-dozen  gallon  bottles  of  formulae  on  the 
shelves  of  the  pharmacy,  and  it  was  a  rare  case  and  a  brave  doctor  that  needed  to 
go  outside  of  that  precious  coterie  of  nostrums.  That  isn't  quite  true  to-day; 
prescriptions  are  written  and  compounded  for  individuals,  not  classes,  and  to  meet 
the  actual  conditions  of  the  particular  case,  and  not  to  meet  the  requirements  of 
a  type. 

CALORIC  VALUES  IN  DIET 

Nearly  all  doctors  who  practice  in  our  institutions  know,  in  a  general  way,  that 
a  full  diet  for  a  well  person  at  hard  work  means  about  3000  calories  daily  when  chem- 
ically analyzed;  that  a  well  person  not  at  work  can  live  on  considerably  fewer  calo- 
ries, and  these  caloric  values  are  figured  out  with  a  pretty  general  uniformity  for 
sick  people  of  various  ages  and  suffering  from  various  diseases,  and  if  we  could  feed 
our  patients  indiscriminately  in  calories,  according  to  the  doctor's  orders,  the 
question  of  hospital  dietetics  would  be  reduced  to  its  simplest  form.  But  digestion 
is  to  a  great  extent  a  process  of  oxidation;  one  person  may  be  capable  of  oxidizing 
and  assimilating  food  material  much  more  completely  than  another;  most  certainly 
this  ability  is  affected  by  manner  of  living,  age,  occupation,  physical  condition, 
habits,  and  constitutional  peculiarities.  Again,  even  a  well  person  will  not  require 
the  same  number  of  calories  at  different  seasons  of  the  year,  or  in  performing  differ- 
ent kinds  of  labor,  or  in  different  environment;  so  that,  no  hard-and-fast  rule  can 
be  laid  down  for  measuring  foods  in  calories,  even  in  conditions  of  health,  how  much 
less  so  in  varying  conditions  of  disease?  Moreover,  caloric  values  take  no  account 
of  interdicted  chemic  constituents  of  food,  except  in  a  very  limited  degree,  and  if 
a  physician  undertook  to  feed  his  diabetic  patient  in  calories  the  hospital  diet 
kitchen  might  make  up  a  large  percentage  of  the  prescribed  allowance  in  a  sugar- 
bearing  food.  If,  on  the  other  hand,  we  take  the  remaining  horn  of  the  dilemma, 
and  undertake  to  select  a  diet  for  any  case  or  for  a  class  of  cases  by  the  thumb-rule 
method  of  printed  diet  lists,  we  must  ignore  entirely  the  part  that  individuality 
plays,  and  depart  quite  as  far  from  a  scientific  basis  as  though  we  had  taken  the 
route  of  the  calories. 

If,  therefore,  we,  as  hospital  caterers  to  the  medical  profession,  undertake 
to  invade  the  realms  of  physiology  and  chemistry  in  the  conduct  of  our  dietary, 
we  find  ourselves  under  the  necessity  of  reckoning  with  each  physician  in  the  insti- 
tution in  a  different  way,  and  of  becoming  involved  in  a  difficult  maze  of  chemistry 
and  physiology  and  figures  with  each  individual  patient;  it  is  manifestly  impossible 
to  do  this;  it  is  also  quite  unnecessary. 

It  is  the  doctor's  business  to  prescribe  medicine  for  his  patient,  and  quite  as 
much  so  to  prescribe  a  diet.  The  hospital  will  be  delivering  all  that  can  possibly 
be  expected  of  it  if  it  carries  out  faithfully  and  intelligently  the  doctor's  orders. 
It  is  well  enough  to  have  diet  lists,  because  there  are  a  great  many  physicians  who 
will  not  take  the  trouble  or  time  to  prescribe  a  scientific  diet,  and  there  are  many  who 
do  not  know  what  a  scientific  diet  is.  We  shall  have  occasion  to  use  the  thumb- 
rule  diet  lists  with  many  practitioners,  but  there  are  a  few  scientific  men  in  every 
community  who  do  know  what  they  want  in  the  way  of  diet,  and  whose  results  in 
the  feeding  of  the  sick  entirely  j  ustify  us  in  making  every  effort  to  carry  out  their 
orders. 


HOSI'ITAL    DIETETICS 


407 


This  brings  us  to  the  middle,  and  undoubtedly  the  straight  and  narrow  way  thai 
leads  to  the  future  of  scientific  diet,  the  individual  prescription  for  the  individual 
case,  and  thus  we  come  hack  to  our  starting-point,  that  most  important  of  .-ill 
chemists'  shops,  the  diet  kitchen. 

The  main  question  is.  How  shall  we  create  a  system  that  will  prove  efficient 
in  serving  a  special  diet  to  every  patient  in  the  hospital  who  needs  it,  and  pre- 
cisely according  to  the  doctors'  orders,  continued  over  any  period  of  time  that  it 
may  be  required?   The  answer  deals  entirely  with  the  personnel  of  the  diet  kitchen. 

THE  ORGANIZATION  OF  THE  DIET  KITCHEN 

It  makes  no  difference  whatever  whether  all  the  food  is  cooked  in  the  large 
hospital  kitchen,  or  whether  the  staple  articles  are  cooked  there  and  the  special 
articles  prepared  in  the  diet  kitchen,  or  whether  all  of  the  food  shall  be  bought  for, 


Michael  Reese  Hospital 

Special  Diet  Record 


Admission  No 

Policial 

Location                                                                                                         Intone 

Date  of  Admission                                                                                        Special  or  Floor  Nurse 

Diagnosis                                                                                                        Special  Diet  Nurse 

Special  Diet  for                                                    191 

BREAKFAST 

ART.CLE 

„„s™, 

<*»„„ 

ass 

cSrsa 

-•«"• 

Hydrate 

«■ 

"" 

~* 

c-lon. 

■— *■ 

TOTAL, 

DINNER 

Fig.  148. 

sent  to,  and  cooked  in  the  diet  kitchen.  These  things  are  all  of  economic  value 
only.  The  technic  of  the  serving  department  is  the  essential  thing.  In  the  very 
few  institutions  in  this  country  that  really  aspire  to  a  scientific  dietary  the  various 
classes  of  diets  are  distributed  among  the  persons  employed  to  prepare  the  trays, 
and  these  persons  are  held  to  a  strict  accountability  for  what  goes  on  them.  This 
presupposes,  of  course,  thai  tin-  hospital  discipline  is  rigid  enough  to  maintain  invio- 
late a  tray  that  has  linn  prepared  in  the  diet  kitchen  until  it  reaches  the  patient 
for  whom  it  is  intended.  For  instance,  all  diabetic  trays  will  be  assigned  to  one 
nurse  at  work  in  the  diet  kitchen.  When  a  doctor  prescribes  a  diet  in  detail  for  his 
patient,  she  will  merely  till  the  prescription  and  prepare  the  tray  down  to  the  lasl 
teaspoon,  to  say  nothing  of  every  item  of  food.  In  cases  of  patients  whose  phy- 
sicians merely  prescribe  a  diabetic  diet,  she  will  prepare  the  meal  composed  entirely 
of  articles  taken  from  the  diabetic  list  at  hand.  Each  tray,  when  completed,  con- 
tains the  name  of  the  patient  and  his  bed  number  or  room  number,  and  the  tray  will 


408 


OPERATION    OF   THE    HOSPITAL 


not  again  be  added  to  or  subtracted  from  in  the  slightest  particular  until  it  reaches 
the  patient.  This  naturally  presupposes  a  prompt  service  in  the  transportation 
of  trays  from  the  kitchen  to  the  patient,  else,  however  satisfactory  the  tray  may  be 
from  a  scientific  standpoint,  it  will  reach  the  patient  cold  and  in  bad  order,  will  be 
unappetizing,  and  the  patient  will  not  eat  the  food.  Nor  is  it  sufficient  that  we  get 
the  prescribed  meal  to  the  patient  in  an  attractive  condition,  every  article  carefully 
weighed  down  to  the  gram  or  even  grain;  our  part  is  not  completed  until  the  tray 
is  returned  to  the  nurse  who  set  it,  and  who  is  now  to  weigh  back  every  particle  of 
the  "left-overs,"  and  enter  the  total  actually  consumed  in  the  nursing  or  diet  record 
of  the  day.  However  important  or  unimportant  the  old  diet  list  may  be,  the  con- 
veniently arranged  diet  slip,  that  will  permit  a  quick  and  comprehensive  setting 

^**.jfc.M!5S.  HOSPITAL 

Kami. _ mm! _r*»» SPECIAL...  P.  !A?J1TE.5 CHART 


■DECEMBER 
1910 

5 

6 

7 

8 

9 

10 

11 

\z 

13 

14 

IS 

16 

17 

18 

19 

FOOD 

Meat 

250 

Eggs 

200 

Vegetables 

300 

27oo 

237-4 

Butter 

ISO 

Bread 

75 

Potatoes 

OatGruel 

600 

Protein 

7*7 

54. 

36 

Fat 

166.6 

8.) 

276 

Orb'h'tf 

49.7 

102.6 

16f> 

Nitrogen 

11.9 

8.6 

6.0 

CAL0RIE5 

22A-6 

717 

3393 

URINE 

Amount 

2^0 

2730 

2360 

Spec.Grav. 

1040 

1030 

7022. 

Sugar  % 

ZX 

27 

.82. 

Sugar  Gms. 

53 

737 

I<J.3 

Acetone 

+ 

++ 

++ 

DiaceticAc 

■+- 

+  + 

+  + 

Ammonia 

1.7 

1-9T 

.80 

Nitrogen 

16.7 

16.5 

82b 

te££r      0.10 

0.12. 

•OQ 

Pat's  Weight     113 

109 

111 

I 

Fig.  149. — Method  of  keeping  daily  summary. 

down  of  just  what  the  nurse  has  done  under  this  order  of  things,  is  a  necessity;  such 
a  slip  is  reproduced  as  an  example  of  such  a  form  (Fig.  148). 

Repeat  for  dinner  and  supper  on  same  sheet. 

For  chemic  values  of  food  articles  the  Atwater  tables,  published  by  the 
Agricultural  Department  of  the  Government,  will  be  found  sufficiently  accurate 
for  all  practical  purposes. 

In  connection  with  this  feeding  chart  there  is  used  in  the  Michael  Reese  Hos- 
pital another  chart  for  carrying  out  the  day's  summary,  in  other  words,  the 
patient's  story  of  the  day.  The  chart  used  is  one  shown  elsewhere  under  the 
subject  of  Record  of  Patients.  Figure  149  shows  one  instance  of  how  this  chart 
is  used  in  this  connection.  The  data  can  be  varied  according  to  the  particular 
case,  and  must,  in  any  event,  be  an  individual  matter.    We  may  incorporate  here 


HOSPITAL    DIETETICS  409 

any  blood  examinations  that  may  be  required,  blood-pressures,  and  whatever 
information  that  may  be  wanted  from  day  to  day. 

There  are  some  institutions  in  which  no  pretense  is  made,  or,  from  the  very 

nature  of  things,  no  pretense  can  possibly  be  effectively  marie,  to  conduct  anything 
like  a  scientific  dietary.  However,  even  the  more  modest  hospital  must  furnish  a 
special  diet  of  a  simple  sort  for  patients  that  require  it,  according  to  the  laws  laid 
down  by  the  great  mass  of  modern  physicians.  There  are  not  many  of  these  diets, 
anil  we  give  them  below,  not  in  endorsement  of  them  as  a  sufficient  answer  to  the 
demands  of  the  modern  physician  who  is  capable  of  specializing  in  metabolism,  but 
for  the  benefit  of  the  great  mass  of  general  practitioners  who  have  neither  the  time 
nor  disposition,  even  if  they  had  the  special  training,  to  order  a  more  carefully 
arranged  diet: 

Fluid  Diet 

1.  Milk  ami  foods  derived  from:  9.  Fruit  beverages: 

(in   Koumiss.  (a)  Orangeade. 

(6)  Buttermilk.  (6)  Lemonade. 

(c)   Whey.  (c)   Grape  juice. 

(rf)  Modified   milk — barley,    H20;  (d)  Blackberry  cordial  (home  made), 

limewater.  (e)   Sangarees. 

2.  Broths.  10.  Barley  and  Rice,  H2( ). 

3.  (Iruels.  11.  Albumin  drinks: 

4.  Beef-juice.  (o)   Milk. 

5.  Beef-tea.  (b)  Water. 

6.  Cocoa — hot  or  iced.  12.  Cream  soups. 

7.  Tea — hot  or  iced.  13.  Egg-nog. 

S.  Coffee.  14.  Frozen  desserts. 

15.  Fruit  sangaree. 

Light  Soft  Diet 
In  addition  to  the  fluid  diet: 

1 .  Well-cooked  cereals.  6.  Soft  poached  or  boiled  eggs. 

2.  Purfie.  7.  Gelatins  made  of  sherry,  fruit-juice,  etc. 

3.  Milk-toast.  S.  Raw  beef  sandwiches. 

4.  Junket.  9.  Oranges — juice  only. 

5.  Soft  custards. 

Soft  Diet 
(In  Addition  to  Diet  Lists  I  and  II) 

1 .  Eggs  in  any  way  except  fried  (be  sure  S.  Crackers  and  wafers. 

hard   cooked,  do  not  reach    boiling-           9.  Baked  apples, 

point).  10.  Stewed  fruits. 

2.  Soups.  11.  Oranges. 

3.  Oysters.  12.  Grapes. 

4.  Steak.  13.  Chicken. 
.").  Creamed  chipped  beef.  14.  Squab. 

(I.  Fish — baked  or  broiled.  15.  Sweetbreads. 

7.  Creamed  celery.  16.  Quail. 

Strict  Diabetic  Did 

Meats  or  poultry  of  all  kinds  prepared  without  flour,  bread-crumbs,  etc.  Eggs  and  cheese 
of  all  kinds. 

Pish  prepared  in  any  way  excepting  with  milk  or  flour. 

Fats  of  all  kinds,  in  the  form  of  cream,  butter,  bacon,  olive  oil,  salad  dressings,  etc.  Plenty 
of  Cream  should  be  used  for  cooking. 

Vegetables:  Lettuce,  cress,  celery,  tomatoes,  young  green  beans,  onions,  radishes,  asparagus, 
Brussels  sprouts,  rhubarb,  cauliflower,  artichokes,  spinach,  cabbage,  mushrooms,  pickles,  sauer- 
kraut, olives. 

Soups  made  of  meat  or  extracts  with  egg  or  any  of  the  above  vegetables, 

Desserts  prepared  from  eggs,  cream,  gelatin  sweetened  with  saccharin,  instead  of  sugar  and 

flavored  with  vanilla,  coffee,  almonds,  etc. 

Stewed  rhubarb  or  gooseberries  Bweetened  with  saccharin. 

Xuts  of  any  kind  excepting  chest  nuts. 

Beverages:  Water,  mineral  waters,  tea,  coffee  (with  saccharin  in  place  of  sugar),  occasionally 
a  little  cocoa;  lemonade  sweetened  with  saccharin  or  glycerin;  buttermilk  in  moderate  quantities 
Everything  not  expressly  mentioned  above  i~  forbidden. 


410  OPERATION    OF    THE    HOSPITAL 

Diet  Low  in  Albumin 
(So-called  "Nitrogen-free  Diet") 
Fruits  of  all  kinds — fresh  or  stewed. 

Potatoes,  carrots,  cabbage,  cauliflower,  spinach,  sauerkraut,  asparagus,  radishes,  lettuce, 
cucumbers,  tomatoes,  mushrooms. 

Fats  of  all  kinds — butter,  cream,  olive  oil  on  salad  dressing  or  in  mayonnaise,  lard — sugar 
in  abundance. 

Bran  bread  and  moderate  amounts  of  wheat  bread.    Toast,  zwieback,  sweet  crackers. 
Beverages — water,  claret,  sweet  wines  or  liquors.     Small  amounts  of  milk  or  buttermilk. 

In  the  Michael  Reese  Hospital,  where  at  least  a  serious  attempt  is  made  to 
conduct  a  dietary  along  these  suggested  lines,  the  established  order  of  procedure 
is  about  as  follows: 

Most  of  the  staple  articles  of  food  for  the  special  diet  patients  are  cooked  in 
the  main  kitchen,  such  as  clear  soups,  roasts,  potatoes  (baked,  boiled,  or  mashed), 
the  commoner  vegetables,  such  as  beans,  peas,  corn  and  tomatoes,  and  perhaps 
the  dessert  of  the  day.  The  diet  kitchen  cooks  its  meats,  broils  or  bakes  its  own 
birds,  makes  its  own  cream  soups,  because  cream  soup  is  an  article  that  cannot  be 
prepared  in  large  quantities  advantageously,  prepares  its  own  salads,  and  makes  its 
own  jellies  and  custards. 

The  diet  kitchen  requisitions  the  staple  foods  that  it  may  need  from  the  main 
kitchen,  and  these  are  sent  in  in  ample  time  for  the  making  up  of  trays,  and  placed 
in  a  steam  table  maintained  for  the  purpose.  The  trays  are  made  up  from  these 
foods,  each  nurse  at  work  in  the  diet  kitchen  preparing  the  trays  for  which  she 
is  to  be  held  responsible.  It  is  a  part  of  the  training  to  know  just  at  what  minute 
a  certain  food  may  be  set  on  the  stove  to  cook,  or  placed  on  the  tray  to  serve,  and 
the  exactness  and  efficiency  of  the  training  will  determine  the  condition  of  the  food 
when  it  reaches  the  patient.  When  ready,  the  food  is  transported  immediately 
from  the  diet  kitchen  by  dumb-waiter  on  the  trays,  as  expeditiously  as  the  dis- 
cipline of  the  hospital  provides,  to  the  patient  for  whom  it  is  intended. 

If  this  system  is  conscientiously  and  rigidly  carried  out,  and  if  delinquent  or 
inefficient  nurses  are  disciplined  whenever  something  goes  wrong  in  their  depart- 
ment, there  will  soon  come  a  routine  of  service  that  will  meet  at  least  most  require- 
ments of  the  medical  profession,  and  if  this  system  is  carried  out,  and  a  patient, 
for  instance,  that  is  under  treatment  for  diabetes  has  a  "run-up"  of  sugar,  the  hospi- 
tal administration  and  diet  kitchen  will  be  held  blameless. 

In  regard  to  the  nurses  and  their  responsibility,  it  is  the  experience  in  the 
Michael  Reese  Hospital  that,  when  the  nurses  are  kept  in  touch  with  the  progress 
of  the  patients  they  are  serving,  they  will  take  the  most  lively  interest  in  their 
work,  and  will  strive  conscientiously  to  get  results,  and  records  that  show  improve- 
ment mean  as  much  to  them  as  they  can  mean  to  the  doctor. 

This  dietetic  rigidity  can  be  aided  very  materially  if,  instead  of  the  ordinary 
tray  for  the  preparation  and  transportation  of  food,  there  is  employed  some  such 
individual  serving  steamer  as  that  indicated  under  the  section  on  Equipment  of 
the  Serving  Rooms.  This  little  individual  server  performs  a  twofold  duty  for  this 
purpose;  it  not  only  keeps  the  food  hot  and  in  very  excellent  condition  for  the 
patient;  it  not  only,  by  reason  of  its  coverings,  minimizes  the  likelihood  of  some 
article  being  added  to  or  taken  from  it  in  transit,  but,  because  of  its  very  individual- 
ism, there  is  impressed  upon  the  mind  of  the  nurse  the  importance  of  care  in  its 
preparation;  in  other  words,  it  looks  formidable  to  the  nurse;  it  is  different  from  the 
ordinary  tray,  and  the  nurse  will  soon  learn  to  respect  that  difference,  and  to 
respect  the  sanctity  of  these  special  trays. 

The  nurses  are  taught,  as  a  part  of  their  diet-kitchen  training,  the  chief  food 


Ill  ISP1TAL   DIETETICS  I  1  1 

value  of  all  the  articles  used  in  their  department,  why  they  are  used,  and  what  the 
results  will  be  to  the  patient  if  other  foods  are  used,  so  that  they  have  an  actual 
working  knowledge  of  what  they  are  doing.  They  arc  required  to  make  ou1  their 
own  menus  from  day  to  day  in  the  cases  not  specifically  prescribed  for  by  the 
physicians,  and  it  is  a  further  part  of  the  training  to  defend  their  menus  in  class. 
Alter  a  time  the  pupil  nurse  finds  the  problem  of  weighing  out  and  compounding 
her  own  prescriptions  a  most  fascinating  one,  and  her  own  failures,  as  evidenced  in 
the  records  of  her  patients,  are  the  most  acute  punishment  she  can  receive  for 
careless  or  poor  judgment. 

SPECIAL  DIET  IN  THE  SMALL  HOSPITAL 

The  small,  economically  administered  institution  cannot  afford  a  very  elabo- 
rate equipment  or  a  large  corps  of  people  to  conduct  the  diet  kitchen,  nor  is  this 
necessary. 

Very  much  good  work  can  be  done  if  the  organization  is  compact  and  the  routine 
well  arranged.  In  many  institutions  there  is  a  disposition  to  complicate  the 
technic  everywhere,  including  the  dietary,  by  division  into  too  many  units — too 
many  avenues  of  transportation,  too  many  serving  rooms,  and  too  many  peoples' 
fingers  in  too  many  things. 

In  a  hospital  of,  say,  50  beds,  there  will  hardly  be  more  than  ten  special  diets — 
at  least  special  enough  to  be  dignified  by  that  term.  One  person,  even  an  under- 
graduate senior  nurse,  can  make  up  that  many  trays,  with  what  food  she  can  pre- 
pare specially  added  to  what  she  can  obtain  from  the  main  kitchen,  and  there  ought 
not  be  any  great  difficulty  about  getting  that  many  trays  directly  to  the  patients. 
even  if  they  have  to  be  carried  one  at  a  time  by  an  orderly  or  maid  if  a  nurse  is  not 
available. 

Where  such  a  practice  is  attempted,  the  really  essential  thing  is  plenty  of  room 
for  the  diet  nurse.  She  ought  to  have  a  quick-acting,  roomy  gas  range  with 
toasting  and  broiling  compartments;  a  good  and  conveniently  arranged  steam  tabic 
and  plenty  of  shelf  room.  It  will  be  wholly  impossible  for  a  nurse  or  anyone  to 
gather  up  food  here  and  there  in  the  main  kitchen,  and  assemble  it  in  some  out-of- 
the-way  corner,  and,  if  she  is  required  to  do  so,  she  will  soon  become  quite  as  care- 
less and  negligent  as  was  the  superintendent  who  prescribed  such  a  routine  prac- 
tice. 


MILK  IN  THE  HOSPITAL 

It  must  be  recognized  by  all  hospital  and  institution  administrators  that  the 
use  and  care  of  milk  are  among  the  most  important  features  of  food  management. 
This  would  not  be  true  if  it  were  possible  for  institutions  to  own  their  own  herds  and 
to  milk  their  stock  under  hygienic  and  clean  conditions,  but  that  is  not  the  case 
usually,  and  it  is  growing  less  possible  every  day,  owing  largely  to  increased  prices 
of  land  and  the  necessity  to  operate  institutions  in  close  proximity  to  largely  popu- 
lated districts  in  which  land  values  are  practically  prohibitive  for  agricultural 
purposes.  State  institutions,  asylums,  sanitoriums,  orphanages,  and  "homes" 
for  the  aged,  for  children,  and  for  defectives  are  exceptions  to  this  rule,  because 
candidates  for  admission  to  these  institutions  are  not  acutely  sick,  and  may  be 
transported  out  into  the  country  where  ideal  conditions  for  their  care  are  to  be 
found.  Even  hospitals  for  acute  diseases,  in  the  smaller  cities  and  towns,  may 
sometimes  be  located  just  outside  the  populous  area,  where  land  is  not  high  priced. 
Such  institutions  may  and  should  own  their  own  farms  and  produce  very  sub- 
stantial proportions  of  their  food  supplies,  including,  in  any  event,  poultry  and  dairy 
products.  But  in  the  metropolitan  hospitals  the  milk  problem  is  becoming  more 
acute  and  annoying  year  by  year,  not  the  least  important  factor  in  which  is  the 
ever-growing  arrogance,  greed,  and  dishonesty  of  the  milk  trusts.  These  iniqui- 
tous corporations,  trafficking  as  they  do  shamelessly  in  the  lives  of  children  and 
infants,  have  reached  a  point  where  they  have  representation  in  nearly  every  legis- 
lative body  and  astute  lawyers  in  every  court.  They  have  set  their  tentacles  into 
every  farm  in  the  land,  and  have  so  arranged  matters  in  many  places  that  if  a  far- 
mer dares  to  sell  to  the  consumer  they  are  enabled  to  shut  his  milk  out  of  the  market 
on  some  flimsy  pretext;  in  some  cities  they  have  strength  to  defy  the  health  author- 
ities, and  even  go  so  far  as  to  attack  the  personal  character  and  integrity  of  sworn 
officers  of  the  law,  men  who  have  the  interests  of  the  people  at  heart  and  whom  the 
people  implicitly  trust.  These  corporations  have  gone  even  farther,  and  in  one 
city  at  least  on  one  occasion  they  made  common  cause  with  a  labor  union  to  pre- 
vent the  delivery  of  milk  to  a  charity  hospital  in  order  to  enforce  their  monopoly. 

During  the  winter  of  1910-11  in  the  Middle  West  these  companies  charged  from 
22  to  24  cents  per  gallon  for  a  most  indifferent  quality  of  milk  as  to  age,  bacterial 
count,  and  cleanliness,  when  the  farmers  were  being  paid  12  cents  or  less.  It  is 
this  condition  that  has  brought  the  milk  question  for  institutions  into  the  forefront 
as  a  most  vital  and  pressing  one.  A  few  institutions,  hotels,  hospitals,  and  the 
like  have  settled  the  question  for  themselves  by  buying  farms  at  nearby  points  in 
the  country,  with  railway  delivery  points  convenient  both  to  the  farm  and  the 
institution;  and  these  institutions  are  profiting  by  the  experiment  in  the  quality, 
cleanliness,  and  price  of  their  milk.  The  starting-point  in  all  these  innovations 
has  been  the  underlying  belief  that  if  the  average  farmer  of  the  country,  unscien- 
tific and  extravagant  in  his  methods,  can  produce  milk  and  do  well  enough  to  even 
live  and  remain  in  the  business  at  a  price  of  3  or  4  cents  per  quart,  why  cannot  an 
efficiently  conducted  dairy  enterprise,  operated  on  proper  economic  lines,  do  the 
same,  or,  at  the  very  least,  do  well  enough  to  produce  clean  milk,  have  it  delivered 
promptly,  and  save  at  least  a  part  of  the  middleman's  profit. 


MILK    I\    THE    HOSPITAL  41o 

The  great  majority  of  institutions,  however,  have  no  such  settlement  of  the 
perplexing  question  in  sight,  and  must  solve  the  problem  in  some  way  with  condi- 
tions as  they  are. 

A  great  many  cities  are  very  properly  compelling  the  pasteurization  of  the 
public  milk  supply  as  the  least  harmful  horn  of  an  almost  hopeless  dilemma;  it  is 
either  that  or  disease  germs  and  filth.  If  private  families  had  facilities,  knowledge, 
and  initiative  sufficient  to  pasteurize  their  own  milk,  it  would  he  better  for  sanitary 
bureaus  to  allow  the  delivery  of  raw  milk  even  if  it  was  bad,  but  the  public  must 
be  protected  against  its  own  ignorance  and  incapacity;  hence  the  milk  is  pasteurized 
in  a  makeshift  way,  and  if  the  toxins  are  left  to  work  out  their  damage  to  helpless 
infants  at  least  some  of  the  pathogenic  bacteria  are  destroyed.  The  average 
institution  is  not  quite  so  helpless  as  the  balance  of  the  public,  because  it  is  always 
possible  to  operate  a  milk  laboratory  in  connection  with  the  institution.  When 
this  is  done,  the  unsanitary  and  disadvantageous  conditions  under  which  milk  is 
furnished  can  lie  to  a  very  large  extent  discounted. 

No  one  who  understands  the  subject  will  propose  the  pasteurization  of  milk, 
provided  it  can  be  controlled  from  the  time  it  leaves  the  cow  until  it  reaches  the 
consumer.  Indeed,  it  is  merely  the  best  of  a  bad  bargain  which  the  exponents  of 
pasteurization  urge,  and  pasteurization  will  cease  of  its  own  accord  whenever  good 
milk  can  be  supplied  raw,  fresh,  and  clean. 

TREATMENT  OF  MILK 

In  approaching  the  subject  of  milk  handling  for  institutions  we  may  recognize 
two,  or  perhaps  better  still,  three  forms  of  the  commodity. 

The  first,  and  by  far  the  most  important  on  the  score  of  quality,  is  the  milk 
for  infants;  second,  milk  for  the  diet  of  sick  adults;  third,  the  general  supply  for 
the  hospital,  for  well  people  to  drink,  and  for  cooking  purposes.  Naturally,  there 
can  be  no  compromise  in  milk  for  sick  children.  A  vast  majority  of  the  ills  of 
infancy  are  gastro-intestinal;  old  milk  is  almost  as  harmful  pasteurized  as  raw,  and 
often  more  so,  because  while  the  pasteurization  may  destroy  all  pathogenic  micro- 
organisms, the  toxins,  the  product  of  these,  have  been  retained,  although  no  micro- 
scope will  develop  their  presence,  so  that  the  evil  is  hidden  and  oftentimes  unsus- 
pected.  Moreover,  in  the  ordinary  commercial  way  of  pasteurization  with  the 
so-called  "flash"  method,  uneven  and  incomplete  as  it  is,  some  particles  will  be 
actually  cooked:  and  this  cooking  serves  to  coagulate  the  lacto-albumins  and  fix 
the  caseins,  and  thus  create  a  food  quite  as  indigestible  in  the  gastro-intestinal 
mechanism  of  a  sick  baby  as  the  hard-boiled  white  of  egg;  other  particles  of  the 
milk  run  the  gauntlet  of  the  conic  toboggan  and  their  micro-organic  inhabitants 
escape  even  a  setback  to  their  activities;  then  when  such  milk  is  allowed  to  rest 
after  the  process,  more  especially  if  the  temperature  is  not  very  low,  these  patho- 
genic bacteria  find  lodgment  in  the  cooked  particles  (than  which  there  is  no  better 
culture-medium),  because  the  normal  ferments  in  the  shape  of  lactic  acid  bacteria 
have  been  destroyed  and  the  original  power  of  resistance  of  the  milk  has  been  lost. 
Administrators  of  children's  hospitals,  or  general  hospitals  in  which  there  is  a  chil- 
dren's department,  realize  the  impossibility  of  using  any  but  fresh  raw  milk  in  the 
feeding  of  sick  infants  suffering  from  ••summer  complaint"  or  "enteric  fever," 
or  any  of  those  classes  of  disease  referable  to  the  stomach  and  intestines. 

When  the  amount  needed  for  the  sick  children  is  small,  sometimes  one  or  a  few- 
cows  may  be  kept  close  by,  and  the  milking  may  be  controlled  as  to  cleanliness, 
and  the  milk  used  fresh,  or  made  up  into  whatever  formula  the  attending  pedia- 


414  OPERATION    OF   THE    HOSPITAL 

trician  may  prescribe.  There  are  some  institutions  that  make  a  special  contract 
for  the  children's  department,  and  pay  the  added  price  to  insure  its  prompt  delivery 
raw  from  even  considerable  distances  in  the  country,  especially  if  there  is  a  railway 
milk  service  convenient. 

CERTIFIED  MILK 

Those  who  have  given  the  matter  greatest  study  are  very  loathe  to  take  the 
so-called  certified  milks  on  faith.  Most  of  these  certified  milks  are  not  what  they 
are  sold  for.  The  pretense  is  that  they  are  fresh,  raw,  cleanly  drawn,  and  hygienic- 
ally  handled,  but  most  of  them  are  prepared  milks.  As  a  rule  the  certified  milk 
is  separated  from  its  cream;  enough  additional  cream  is  added  to  bring  up  the 
butter-fat  content  to  4  per  cent,  or  whatever  the  commodity  is  sold  at;  and  the 
milk  and  cream  are  again  mixed,  so  that  the  precise  contract  as  to  quality  can  be 
complied  with.  If  this  separation  and  remixing  were  done  on  scientific  principles 
there  would  be  no  harm  in  the  process,  but  unfortunately  this  is  rarely  the  case. 

We  hear  and  read  a  good  deal  lately  about  "Holstein"  milk  for  sick  children, 
and  there  is  a  reason  for  this  which  it  might  be  profitable  for  us  to  follow  briefly. 
The  Michael  Reese  Hospital  went  very  exhaustively  into  the  question  of  milk  for 
sick  children  recently,  and  when  it  came  to  a  study  of  cows'  milk,  an  inquiry  was 
made  into  the  various  breeds  of  cows  with  reference  to  the  quality  and  physiologic 
value  of  milk;  and  it  was  found,  for  instance,  that  many  of  the  most  famous  Jerseys 
could  not  raise  their  own  calves,  and  that  the  beef-cattle  breeders  were  in  the  habit 
of  taking  the  calves  away  from  the  highly  bred  shorthorns  and  other  beef  strains, 
and  giving  the  calves  to  scrub  or  "thin  milk"  cows,  like  the  Holsteins  and  Ayrshires. 
The  greater  value  of  the  mothers  for  other  purposes  was  urged  as  a  reason  for  this 
foster-mother  or  wet-nurse  practice,  but  several  scientific  breeders  were  willing 
to  admit  that  the  calves  seemed  to  do  better  on  thin  milk. 

The  butter-fat  globule  of  the  Alderney,  Jersey,  and  Guernsey  milk  is  very  much 
larger  than  that  of  the  scrub  or  thin  milk  varieties,  and  the  shorthorn  is  a  close 
second  in  the  size  of  the  globule.  It  is  believed  by  those  who  made  the  experiments 
that  the  size  of  this  fat  globule  has  a  great  deal  to  do  with  the  digestibility  of  the 
milk,  though  not  enough  experimental  work  has  yet  been  done  to  prove  this  to  be 
the  case.  If  this  is  true,  then  it  goes  without  saying  that  the  custom  of  adding 
cream  to  certified  milk  to  bring  it  up  to  the  charmed  "4  per  cent."  so  anxiously 
sought  by  milk  buyers,  is  a  most  pernicious  one,  because  these  certified  milk  people 
are  accustomed  to  keep  enough  Jersey  cows  to  furnish  the  required  balance.  Most 
Holstein  and  other  thin  milk  cows  do  not  give  a  4  per  cent,  milk,  and  many  of  them 
do  not  go  as  high  as  3  per  cent.,  but  it  seems  from  the  experiments  above  alluded 
to  that  the  thinner  the  milk,  the  smaller  the  fat  globule.  In  the  same  set  of  experi- 
ments the  fat  globule  of  the  human  milk  was  found  to  be  smaller  than  that  of  any 
other  animal;  that  of  the  ass  came  second,  and  the  milk  of  the  ass  has  long  been 
used,  where  that  animal  is  common,  for  feeding  sick  babies;  the  goat  came  third  in 
respect  of  the  smallness  of  the  globule,  and  goats'  milk  for  infants'  feeding  has  long 
been  recognized  as  an  excellent  substitute  for  mothers'  milk. 

In  view  of  these  citations,  speculative  though  they  be  to  a  certain  extent,  it 
would  seem  highly  desirable  to  consider  not  alone  those  virtues  in  milk  with  which 
we  are  most  familiar,  and  which  are  exploited  as  peculiar  to  certified  milk,  but  to 
question  other  qualities  in  a  milk  when  things  go  wrong  in  the  children's  service. 
Having  obtained,  then,  the  best  milk  possible  for  our  sick  children  under  existing 
circumstances,  we  bring  it  to  the  milk  rooms  of  the  institution  ready  for  treatment 
in  one  of  the  many  ways  required  by  the  children's  doctors. 


MILK    I.V    THK    HOSPITAL 


415 


TREATMENT   OF  CHILDREN'S  MILK 

There  are  three  steps  in  the  handling;  of  milk  that  must  be  provided  for:  first. 
pasteurization;  second,  sterilization;  third,  formulation  by  prescription.  Pasteur- 
ization is  the  most  important  because  the  most  delicate  of  these  necessities.  At 
the  present  time  there  seems  to  be  a  single  pasteurization  mechanism  offered  for 
sale  that  is  worth  consideration.  That  in  which  the  milk  is  supposedly  pasteurized 
as  it  passes  down  a  conically  shaped  heated  surface  is  just  a  little  the  worst  form  of 
pasteurizer  that  could  well  be  conceived.  Usually  these  machines  have  a  rope  or 
scraper  of  some  sort  bearing  upon  the  surface  of  the  metallic  cone  for  scraping  the 
cooked  milk  particles  away,  so  that  other  particles  may  reach  the  heated  surface. 
The  result  is  that  some  of  the  milk  is  actually  cooked  and  some  of  it  is  not  even 
heated.     Other  milk  pasteurizers  are  essentially  tanks  in  which  the  milk  is  heated 


Pig.  150. — Author's  milk  pasteurizer. 

in  hulk;  if  this  were  done  under  careful  conditions  it  would  he  really  not  so  had. 
but  it  is  never  done  under  such  conditions,  and  this  is  the  class  of  milk  oftenesl 
found  to  be  filled  with  manure  and  a  general  assortment  of  tilth,  including  Hies 
and  other  vermin. 

We  must  conclude  that  at  the  present  time  there  is  no  known  method  by  which 
milk  is  now  efficiently  pasteurized  in  a  commercial  way;  the  deduction  follows  that 
institutions  must  provide  their  own  means.  We  are  indebted  to  the  pathologists 
for  a  hint  as  to  the  most  efficient  and  practical  means  of  pasteurization.  These 
gentlemen,  when  they  wish  to  arrive  at  a  technical,  correct  pasteurization  for 
laboratory  purposes,  do  the  work  by  complete  immersion  of  the  milk  under  water, 
and  perhaps  the  most  illuminating  technical  result  we  have  for  our  guidance  was 
accomplished  by  Rosenau,  of  the  Bacteriological  Division  of  the  Department  of 
Agriculture.     Dr.  Kosenau's  work  was  on  a  test-tube  basis  only,  hut  he  attained 


416  OPERATION    OF    THE    HOSPITAL 

accurate  and  exact  results  in  the  determination  of  the  thermal  death-point  of  the 
pathogenic  bacteria,  and  his  results  may  be  taken  as  our  guide,  because  in  his 
pasteurization  he  accomplished  the  results  for  which  we  are  contending,  that  is, 
the  heat  point  and  the  time  required  for  the  destruction  of  the  various  forms  of 
pathogenic  or  harmful  bacteria,  such  as  colon  bacilli,  the  tubercle  bacilli,  dysentery, 
and  typhoid,  and  it  is  really  these  bacteria  that  we  are  undertaking  to  kill. 

Working  upon  the  basis  of  Dr.  Rosenau's  technic,  we  have  designed  a  pasteurizer 
in  the  Michael  Reese  Hospital  on  a  scale  that  may  be  increased  or  diminished  to 


Fig.  151. — Ehrlenmeyer  flasks  with  cork  and  tube. 

meet  the  needs  of  a  very  small  or  a  very  large  institution.  Figure  150  shows  this 
mechanism  as  it  is  operated.  The  cupboard  in  the  lower  part  of  the  machine  is 
merely  to  house  the  necessary  flasks  when  not  in  use,  the  working  part  of  the 
machine  consisting  of  a  reservoir  of  sufficient  size  into  which  opens  a  cold-  and  a 
hot-water  pipe  controlled  by  cocks.  At  the  left  of  the  machine  steam  coils  are  let 
into  the  bottom  of  the  reservoir  sufficient  in  number  to  heat  the  water  rapidly. 
The  admission  of  steam  through  these  pipes  is  controlled  by  an  ordinary  Powers' 
automatic  temperature  regulator  or  a  device  of  similar  design.  This  temperature 
regulator  is  set  to  provide  the  temperature  required.     The  milk  containers  are 


MILK    IN    TIIK    HOSPITAL  417 

ordinary  2-liter  laboratory  Ehrlenmeyer  flasks  such  as  those  pictured  in  Fig.  151. 
These  flasks  are  fitted  with  soft-rubber  corks,  one  used  as  the  control,  the  cork  of 
which  contains  a  standardized  thermometer.  The  process  of  operation  is  one  of 
thumb-rule.  The  possibilities  of  the  machine  having  been  tested,  the  method  is 
to  fill  the  reservoir  with  water;  if  the  water  is  hot  the  temperature  is  more  quickly 
reached;  if  the  water  is  cold  it  will  take  longer  to  heat.  Cold  water  is  preferable 
if  it  is  designed  to  continuously  employ  the  control  thermometer  to  indicate  the 
stage  of  the  process.  These  flasks  filled  with  milk  up  to  a  definite  point,  and  the 
rubber  corks  tightly  fitted,  are  completely  immersed  in  the  water.  Dr.  Rosenau 
allowed  the  milk  to  reach  the  temperature  of  the  water,  which,  for  his  purposes, 
was  fixed  at  60°  C,  140°  F.,  and  he  then  maintained  that  temperature  for  twenty 
minutes.  He  found  that  with  this  heat  all  the  pathogenic  bacteria  were  destroyed, 
and  that  the  milk  itself  was  left  chemically  unaltered,  that  is,  the  lacto-albumins 
were  not  coagulated  and  the  caseins  were  not  fixed,  as  would  have  been  the  case  if 
the  temperature  had  gone  higher  or  was  maintained  longer.  It  will  not  do  to  leave 
the  corks  of  the  flasks  exposed  above  the  surface  of  the  water,  because  the  bacteria 
on  and  under  the  corks  will  not  have  been  reached  by  a  sufficient  degree  of  heat  for 
a  sufficient  length  of  time  to  destroy  them,  and  the  milk  is  more  than  likely  to  be 
reinfected  as  it  is  poured  from  the  flasks.  Glass  tubes  in  the  corks  allow  for  ex- 
pansion under  heat. 

It  is  important  to  have  a  by-pass  around  the  regulator,  so  that  if  a  much  higher 
temperature  is  required,  as,  for  instance,  in  the  complete  sterilization  of  milk,  the 
steam  can  be  turned  into  the  coils  without  the  control  of  the  automatic  regulator. 
In  this  way  milk  may  be  boiled  or  brought  up  to  any  required  temperature,  always 
assuming  that  the  control  flask  and  the  thermometer  are  in  operation.  It  is  not  a 
difficult  matter  to  determine  for  the  working  purposes  of  the  milk  operator,  a  nurse 
or  other  intelligent  woman,  just  how  long  it  will  take  for  the  milk  in  the  flasks  to 
arrive  at  the  temperature  of  the  water  in  the  tank,  given  the  number  of  flasks  to  be 
heated  and  the  temperature  of  the  water  at  the  outset,  and  this  technic  should  be 
established  for  the  operator  before  she  is  entrusted  with  the  wrork. 

It  was  found  in  the  Michael  Reese  Hospital  that  when  the  milk  and  air  in  the 
submerged  flasks  became  heated  there  wras  sometimes  sufficient  expansion  to  blowT 
the  corks  from  the  flasks,  and  to  remedy  this  each  rubber  cork  was  fitted  with  a 
glass  tube;  in  this  way  an  escape  was  furnished  for  the  expanding  air  or  milk. 
Figure  151  shows  this  mechanism. 

STERILIZATION  AND  FORMULAE  MILKS 

The  so-called  lactic  acid  bacteria  are  hardier  than  any  of  the  pathogenic  micro- 
organisms we  have  commonly  to  reckon  with,  and  after  Rosenau's  process  there  are 
many  of  these  harmless  bacteria  remaining  alive,  and  subsequently  their  activities 
may  lie  re-established  and  the  milk  go  on  to  the  physiologic  processes  of  fermenta- 
tion, and  in  those  cases  of  disease  where  pasteurized  milk  is  available  this  is  a  wel- 
come culmination;  there  are  many  diseases  and  stages  of  disease,  however,  in  which 
even  so  mild  a  fermentative  process  cannot  be  borne  and  in  which  the  whole  gasl  ro- 
intestinal  tract  is  practically  out  of  commission,  and  it  becomes  necessary  to  still 
further  modify  the  feedings;  this  is  done  by  resort  to  a  species  of  predigestion  in 
which  a  completely  sterilized  milk  is  employed  as  a  basis  to  destroy  every  possible 
ferment,  and  in  which  the  second  stage  of  preparation  is  the  addition,  under  certain 
conditions,  of  an  artificial  ferment  in  the  form  of  a  prepared  rennet.  It  is  not  a 
difficult  matter  to  sterilize  milk  in  preparation  for  its  formulation  into  prescriptions 


418  OPERATION   OF   THE    HOSPITAL 

for  individual  cases;  it  may  be  done  in  the  pasteurizer  by  increasing  the  heat  or, 
especially,  by  increasing  the  time.  Care  ought  to  be  taken  not  to  carry  the  heating 
too  far,  since  there  is  danger  of  creating  very  radical  changes  in  the  chemistry  of  the 
milk  and  so  destroying  it  altogether.  Rosenau's  process,  using  140°  F.,  carried  for 
forty  minutes  after  the  milk  has  reached  the  desired  temperature,  is  adequate. 
The  cooling  of  milk  after  either  pasteurization  or  sterilization  should  be  accomplished 
as  quickly  as  possible,  with  due  regard  to  the  breakage  of  the  flasks.  For  this 
purpose  a  long  trough  with  three  or  four  compartments  may  be  used:  the  first  to 
contain  warm  water,  the  second  to  contain  water  of  a  considerably  lower  tempera- 
ture, a  third,  of  a  still  lower  temperature,  and  if  there  is  a  fourth  compartment,  the 
water  in  it  may  be  cold.  Each  of  these  compartments  has  a  vent  for  the  escape  of 
the  water  after  it  has  arrived  at  a  height  that  will  cover  practically  all  the  milk. 
After  this  cooling,  the  milk  may  be  set  in  the  refrigerator  and  kept  for  practically 
any  period  of  time. 

There  are  certain  formula  of  milk  employed  in  common  by  modern  pediatricians, 
and  since  a  discussion  of  their  purposes  and  the  avenues  of  their  usefulness  would 
bring  us  far  into  the  realm  of  medicinal  practice,  we  shall  find  it  profitable  to  merely 
set  down  the  commoner  ones,  with  the  laboratory  notes  for  their  dispensing: 

Peptonized  Milk 

1  pint  milk. 

1  peptonizing  tube  or  3-grain  tablet;  mix  in  a  little  cold  water  and  add 
to  milk.  Put  in  cold  water-bath  and  bring  to  temperature  of  120°  F.,  allow- 
ing milk  to  stand  for  nine  minutes.     Place  immediately  on  ice. 

Kellar's  Malt  Soup 

Take  of  wheat  flour  2  ounces  and  add  to  it  11  ounces  of  milk.  Soak  the 
flour  thoroughly  and  rub  it  through  a  strainer.  Put  into  a  second  dish  20 
ounces  of  water,  to  which  add  3  ounces  of  malt  extract;  dissolve  the  above  at  - 
a  temperature  of  about  120°  F.  and  then  add  2;  drams  of  11  per  cent,  potas- 
sium bicarbonate  solution.  Finallj-,  mix  all  of  the  above  ingredients  and  boil. 
This  gives  a  food  containing  albuminoids,  2.0  per  cent.;  fat,  1.2  per  cent.; 
carbohydrates,  12.1  per  cent.  There  are  in  this  mixture  0.9  per  cent,  of  vege- 
table proteins. 

Whey 

Add  to  1  pint  of  fresh  lukewarm  (98°  F.)  milk  1  teaspoonful  of  liquid 
rennet.  Allow  milk  to  stand  in  warm  place  until  firmly  coagulated.  When 
the  curd  has  formed,  beat  up  with  a  fork  and  allow  it  to  stand  for  some  moments 
until  the  curds  have  shrunk  considerably;  strain  off  whey  through  cheese-cloth  or 
silk;  then  heat  whey  to  a  temperature  of  150°  F.,  thus  destroying  further  action 
of  rennet. 

Buttermilk  Formula 

First  mix  with  a  small  amount  of  cold  fresh  buttermilk  40  grams  or  2 
ounces  of  wheat  or  barley  flour;  then  add  enough  buttermilk  to  make  1  liter; 
gradually  stir  in  60  grams  or  2  ounces  of  sugar  and  bring  mixture  to  a  boil; 
after  it  has  boiled  for  twenty  minutes,  being  stirred  constant^,  it  is  placed 
in  ice-chest  and  warmed  before  feeding. 

Directions  for  making  up  the  formulae  or  prescriptions  are  given  in  sufficient 
detail  to  enable  almost  any  one  to  do  the  work  intelligently,  but  we  might  say  a 
word  or  two  about  the  only  formula  that  will  ordinarily  be  open  to  glaring  and 
costly  mistakes  in  dispensing,  and  that  is  buttermilk.  Doctors  are  prescribing 
buttermilk  a  great  deal  of  late  years  under  one  name  or  another,  and  they  seem  not 
to  go  into  the  details,  as  a  rule,  about  how  it  should  be  made.  Most  of  us  know  that 
the  buttermilk  to  be  purchased  of  milk  dealers  is  a  by-product.  If  we  did  not  buy 
it  the  pigs  would  get  it,  and  the  pigs  do  get  a  great  deal  of  it.  The  buttermilk 
bought  from  the  delivery  wagons  is  about  the  filthiest  stuff  imaginable;  the  bacteria 


MILK    IN    THK    HOSPITAL 


419 


it  contains  are  of  every  known  kind,  harmless  and  pathogenic;  its  toxins  arc  ines- 
timable and  its  physical  condition  is  an  abominable  nondescript,  quite  as  dangerous 
in  the  gastro-intestinal  trad  of  a  sick  child  as  a  dynamite  cracker  with  a  slow  fuse 
lighted. 

Buttermilk  can  be  made,  however,  that  is  good — not  only  good  for  the  children 
in  view  of  their  condition,  hut  good  to  drink  from  the  standpoint  of  palatability. 
The  secret  of  the  process  is  to  start  out  with  the  proper  artificial  lactic  acid  bacteria. 
For  a  long  time  the  physiologic  chemists  and,  behind  them,  the  wholesale  drug  houses 
have  been  trying  to  obtain  an  artificial  milk  ripener  that  would  leave  the  buttermilk 
with  a  sweet  and  palatable  taste  instead  of  the  acutely  bitter  after-taste  so  common. 
The  only  ferment  that  seems  to  the  author  to  have  overcome  this  serious  objection 
is  Hansen's  Lactic  Ferment,  to  be  purchased  in  all  the  wholesale  houses. 

A  so-called  starter  or  yeast  is  made  and  kept  going  from  week  to  week,  under 
directions  accompanying  the  package.  The  milk  is  sterilized  to  rid  it  of  all  extran- 
eous ferments  and  pathogenic  bacteria,  and  treated  in  the  way  prescribed  in  the 
directions.  The  milk  may  be  used 
whole,  churned  after  it  has  been  ripened 
ami  the  butter  used  sweet  for  the  salt- 
less  diet  cases  in  the  adult  parts  of  the 
institution,  or  the  milk  may  be  separ- 
ated before  ripening  and  the  cream 
used  for  other  purposes. 

EQUIPMENT  OF  THE  MILK  LABORA- 
TORY 

After  the  pasteurizer,  which  has 
already  been  described,  the  piece  of 
technical  mechanism  of  greatest  im- 
portance is  the  bottle  and  flask  cleaner. 
This  apparatus,  shown  in  Fig.  152, 
is  a  simple  device,  upon  the  cor- 
rectness of  a  few  details  of  which, 
however,  will  depend  its  efficiency, 
and  there  are  many  commercial  elabo- 
rations of  it.  There  are  three  pipes 
leading  to  the  cleaner  jets,  each  con- 
trolled by  a  stop-cock;  one  feeds  cold 
water  in  a  spray  into  the  bottles  on 
demand,  another  feeds  hot  water,  and 
a  third  feeds  live  steam,  all  under  pres- 
sure. The  cold-water  pipe  is  first 
used  to  wash  the  milk  from  the  bot- 
tle, then  the  hot  water  is  turned  in  to 

complete  the  cleaning  process,  and  the  final  step  is  to  completely  sterilize  the 
inside  of  the  bottle  with  live  steam.  It  will  not  do  to  reverse  this  order,  a-  tin- 
hot  water  used  first  will  'fix  the  particles  of  milk  to  the  inside  of  the  glass. 

A  refrigerator  in  the  milk  laboratory  is  absolutely  necessary,  but  need  not  have 
water-tight  compartments  for  setting  the  llasks  of  milk  in  water.  Tanks  of  water 
in  refrigerators  give  rise  to  endless  disagreeable  features,  such  as  spilled  milk  and 
grease,  without  any  compensating  advantages.     The  temperature  of  the  refrigerator 


152. — Bottle  :uiil  flask 


420 


OPERATION    OF    THE    HOSPITAL 


may  be  kept  at  any  desired  point,  and  the  refrigerator  may  be  fitted  with  shelves 
to  contain  any  number  of  receptacles.  It  seems  not  to  be  necessary  to  maintain  a 
temperature  lower  than  40°  F.  in  the  milk  refrigerator. 

The  laboratory  should  contain  a  two-  or  four-burner  gas  range;  oftentimes  it 
is  necessary  to  cook  a  feeding  such  as  barley  or  the  various  pea  or  bean  meals,  and 
the  gas  is  handy  for  such  purposes.  Sometimes,  too,  a  considerable  quantity  of 
sterile  water  may  be  required,  and,  unless  there  is  a  sterilized  water  faucet  in  the 
laboratory,  it  is  convenient  to  sterilize  the  water  with  gas. 


Fig.  153. — Glass-covered  table  for  milk  laboratory. 


Figure  153  shows  a  glass-covered  work  table,  with  drawers  beneath  and  with  a 
center  rack  of  shelves  above.  It  will  be  always  necessary  to  have  sterile  filters  in 
the  laboratory  for  filtering  the  milk,  both  when  it  comes  into  the  laboratory  fresh, 
and  perhaps  afterward  at  some  stage  of  formulation  required. 

Clean  sterile  towels  and  cloth  sieves  of  various  sorts  are  necessary,  and  these 
articles  should  be  sterilized  in  the  ordinary  laparotomy  drum,  such  as  is  shown  on 
the  work  table,  and  they  may  be  kept  sterilized  until  wanted  for  use;  they  should 
be  kept  in  the  drums  in  the  drawers  under  the  work  table.  There  should  also,  of 
course,  be  an  ordinary  wooden  table  connected  with  the  hot- and  cold-water  sink; 
the  top  of  this  table  may  slope  to  the  sink,  and  be  grooved,  such  as  is  used  for 


MILK    IN   THE    HOSPITAL 


421 


ordinary  dish-washing  purposes  in  most  kitchens,  but  this  one  may  be  on  a  larger 
scale. 

The  moving  machinery  of  the  milk  laboratory  may  be  operated  cither  from  a 
main  shafting  placed  on  the  ceiling  on  anchors,  or  may  be  run  on  anchors  just  above 
the  floor.  This  main  shafting  may  he  run  from  a  motor,  and  the  pulleys  operating 
each  machine  may  be  devised  of  a  size  to  give  the  proper  speed  to  each  individual 
machine.  In  the  absence  of  electric  power,  it  will  be  possible,  though  hardly  profit- 
able or  economic,  to  operate  these  machines  by  hand,  and  this  can  be  done  the  more 
easily  with  the  separator  and  churn.  The  essential  pieces  of  machinery  in  this 
room  are  the  separator,  the  ordinary  Sharpies  machine,  selected  in  the  matter  of 
si/.e  according  to  the  amount  of  milk  to  be  separated;  a  churn;  a  Babcock  tester; 
and  some  mechanism  by  which  milk  in  course  of  formulation  into  prescriptions  can 


Fig.  154.  -Apparatus  in  milk  laboratory. 


lie  peptonized  or  prepared,  and  agitated  and  heated  at  the  same  time.  These 
various  machines  are  shown  in  Fig.  154.  The  churn  and  separator  are  generally 
known,  and  will  not  require  description,  excepting  that  it  might  he  well  to  suggest 
that  those  who  contemplate  having  a  churn  that  will  last  for  any  considerable 
length  of  time  ought  to  have  it  made,  and  not  trust  to  the  usual  makes  found  on  the 
market  :  it  seems  there  are  none  that  will  hold  together  working  under  power  for 
longer  than  a  \'vw  weeks.  The  elmni  musl  he  made  of  heavy  galvanized  iron,  pref- 
erably nickeled  on  the  inside,  and  reinforced  with  heavy  hands  both  ways.  The 
lid  must  be  gasketed  with  a  rubber  composition  set  in  between  the  lips  of  a  double- 
lipped  rim,  tonguc-and-grove-like. 

The  peptonizer  for  preparing  a  considerable  number  of  individual  prescriptions, 
especially  for  the  children's  department    (Fig.    155),  is  a   Hat   copper  boiler  sel    up 


422  OPERATION    OF    THE    HOSPITAL 

off  the  floor  so  that  a  circle  of  gas  jets  can  run  beneath  it.  There  are  a  number  of 
holes  in  the  top  of  the  boiler  to  fit  the  containers.  The  boiler  is  pivoted  on  the 
bottom  and  connected  up  to  a  bell  crank  running  from  the  main  shafting,  which, 
when  the  mechanism  is  at  work,  makes  the  boiler  and  its  contents  vibrate  backward 
and  forward  over  about  30  degrees  of  a  circle,  and  this  backward  and  forward  move- 


Fig.  155. — Peptonizer,  or  predigestion  apparatus. 

ment  keeps  the  contents  of  the  cans  stirred  up ;  it  is  a  very  efficient  means  of  cooking 
milk  formulae  so  that  they  will  not  burn  and  so  that  the  solutions  will  cook  well 
mixed.  The  mechanism  is  merely  a  multiple  rice-cooker,  made  to  vibrate  while 
the  contents  of  the  cans  are  simmering  in  the  boiling  water  of  the  tank,  making  it 
unnecessary  for  some  one  to  stand  by  to  stir  the  mixture. 

THE  COMMERCIAL  MILK 

While  we  should  greatly  desire  a  better  quality  of  milk  for  the  sick  adults  in  the 
institution  than  that  which  we  would  be  willing  to  accept  for  culinary  purposes,  and 
for  such  well  people  as  interns  and  nurses,  we  shall  rarely  come  across  conditions 
in  which  a  different  contract  for  these  two  forms  may  be  had  on  account  of  high 
prices  and  difficulties  largely  local. 

In  these  days  of  quick  transportation  and  almost  universal  "milk-train"  service 
in  the  large  centers  of  population  where  the  milk  problem  is  acute,  it  should  be 
possible  to  get  milk  fairly  clean  not  more  than  twenty-four  hours  old  and  trans- 
ported in  iced  cans.  But  for  the  trusts  this  quality  of  milk  service  would  be  the 
rule  everywhere;  as  it  is,  these  combinations  seem  to  dominate  the  transportation 
lines,  and  are  in  many  places  able  to  throw  such  hindrances  in  the  way  of  prompt 
service  that  the  wise  hospital  administrator  prefers  to  employ  his  energies  in  more 
congenial  occupation  than  in  constant  warfare  with  a  situation  in  which  his  oppo- 


MILK    IX    TIIK    HOSPITAL 


423 


nent  lias  all  the  advantage  of  time,  special  talent,  and  a  better  knowledge  of  the 
tricks  of  the  trade. 

Checking  up  the  Milk. — With  all  these  disadvantages,  however,  there  are  a  few 
checks  on  our  milk  supply  thai  may  be  profitably  employed.  If  we  can  gel  our 
supply  from  a  single  producer,  even  through  the  kindly  offices  of  a  member  of  the 
trust,  we  may  exercise  some  small  sort  of  inspection  of  the  herd  and  premises  whence 
the  milk  is  derived.  We  can  filter  out  whatever  filth  we  are  obliged  to  accept.  If 
we  can  prevent  the  pasteurization  of  the  milk  before  we  receive  it,  we  shall  have  the 
right  of  protest,  at  least,  if  the  bacterial  count  runs  high,  as  indicating  the  age  of  the 
product  or  its  improper  handling  in  transit.  When  the  milk  is  permitted  to  be 
pasteurized  before  we  get  it  we  lose  this  opportunity,  because  there  is  no  way,  labo- 
ratory or  otherwise,  to  determine  the  amount  of  toxins  present  until  the  damage 
to  a  sick  child  reveals  the  actual  condition.  If  we  have  a  raw  milk  and  a  bacterial 
count,  we  may  realize  pretty  definitely  how  far  we  can  go  in  giving  the  milk  out  for 
drinking  purposes.  Each  day's  milk  should  be  passed  through  the  institution 
laboratory  by  samples  for  butter-fat  and  for  bacterial  count,  though  there  are  many 
of  us  who  would  prefer  an  undoctored  milk  at  3^  per  cent,  butter-fat  to  a  doctored 
4  per  cent,  article.  The  laboratory  cannot  only  keep  check  on  the  bacterial  count, 
but  by  occasionally  staining  up  for  colon  and  other  bacteria  of  filth,  maintain  some 
sort  of  reckoning  of  the  cleanliness  of  the  stables  and  the  method  of  handling. 

MILK  IN   THE  HOSPITAL 

Nearly  all  the  health  authorities  of  the  larger  cities  are  alive  to  the  intolerable 
milk  situation  and  the  inefficiency  of  the  flash  methods  of  pasteurization.     Recently 


Fig.  156. — Floor  plan  for  milk  station. 


their  activities  have  begun  to  make  an  impression,  and  to  force  a  corresponding 
activity  on  the  part  of  the  milk  venders.  In  many  parts  of  the  country  efforts  are 
now  being  made  to  find  a  "holder"  method  similar  to  the  one  illustrated  from  the 
Michael  Reese  laboratory,  and  which  could  be  made  to  serve  the  purposes  of  a 
large  commercial  necessity. 

The  methods  so  far  developed  are  two  in  number:  one  in  which  the  milk  is  pas- 
teurized in  the  large  100-pound  cans  by  a  system  of  agitation  while  the  can-  re- 
main in  the  tanks,  so  that  the  milk  nearest  the  water  will  not  cook,  while  that  at 
the  center  of  the  cans  remains  indicated;  and  the  other,  a  mechanism  closely  resem- 


424  OPERATION   OF   THE    HOSPITAL 

bling  the  chain-grate  of  the  power  plant.  In  this  method  the  ordinary  quart 
bottles,  fitted  with  rubber  cork  and  glass  tube,  are  immersed  at  one  end  of  the  tank 
on  an  endless  chain-grate  moving  at  a  rate  that  will  keep  each  bottle  under  water 
just  the  length  of  time  necessary  to  achieve  the  desired  result.  As  the  bottles  leave 
the  bath  the  rubber  corks  are  removed  and  sterilized  caps  are  substituted.  This 
last-named  process  promises  to  be  the  method  of  choice  for  the  future.  A  third 
method,  which,  however,  does  not  promise  very  much  from  a  scientific  standpoint, 
consists  of  a  long  coil  of  tube  suspended  in  hot  water.  Each  particle  of  milk  is 
supposed  to  take  a  certain  time  to  traverse  the  tube  and  to  be  pasteurized  on  its 
completion  of  the  journey.  This  method  depends  on  too  many  obvious  hazards 
to  entitle  it  to  very  much  consideration. 

Floor  plans  of  a  very  good  milk  laboratory  are  shown  in  Fig.  156. 


ISOLATION  AND  DISINFECTION 
CLASSIFICATION  OF  DISEASES  FOR  ISOLATION 

The  text-books  on  hygiene  effectively  treat  of  the  communicable  diseases  and 
modern  means  for  their  prevention  and  isolation  under  ordinary  conditions,  and  it 
would  be  a  task  of  repetition  and  compilation  to  go  over  the  general  field  in  a  work 
of  this  character;  we  shall,  therefore,  confine  ourselves  to  a  discussion  of  the  infec- 
tions that  present  themselves  as  problems  in  institutional  management,  and  the 
simpler  and  more  economic  methods  to  be  employed  in  dealing  with  them. 

Discarding,  then,  all  the  classic  groupings  of  the  transmissible  diseases,  let  us 
divide  them  for  our  purposes  into  two  great  divisions,  according  to  the  means  by 
which  their  toxic  properties  may  be  attacked  and  destroyed.  In  this  classification 
we  may  place  in  one  group: 

(a)  The  eruptive  diseases  of  childhood — small-pox,  scarlet  fever,  measles,  chicken- 
pox,  and  German  measles. 

(6)  Those  unclassified  diseases  of  childhood  of  unknown  origin — mumps  and 
whooping-cough. 

(c)  Diseases  with  localization  in  the  respiratory  tract — tuberculosis,  pneumonia, 
and  diphtheria. 

(d)  Those  diseases  referable  more  especially  to  the  gastro-intestinal  tract — 
typhoid  fever,  dysentery,  and  cholera. 

(e)  Erysipelas — a  highly  communicable  streptococcus  infection. 

(/)  Epidemic  cerebrospinal  meningitis  and,  perhaps,  poliomyelitis,  that  is  just 
now  receiving  so  much  attention. 

(g)  Gonorrheal  disease,  expressed  more  particularly  as  a  gonorrheal  vaginitis 
in  infants. 

(h)  Syphilis  produced  by  spirochsetae. 

(i)  Certain  of  the  pyogenic  or  pus  infections,  communicable  to  a  limited  degree 
if  abnormal  conditions  prevail.  Extremely  important  for  our  purposes  is  the 
pyocyaneus,  or  green  pus  infection,  so  common  in  the  surgical  wards  of  unclean 
hospitals;  we  may  likewise  include  here  such  of  the  streptococcus  and  staphylo- 
coccus pus  infections  as  we  recognize  as  postoperative  complications,  and  againsl 
which  we  must  exercise  the  greatest  precautions,  especially  in  operating-  and 
dressing-room  asepsis. 

In  the  second  group  we  shall  include  the  few  but  virulent  diseases  due  to  spore- 
bearing  micro-organisms,  the  chief  peculiarities  of  which  are  shown  by  their  resist- 
ance against  all  known  bactericidal  agents,  and  also  by  the  violence  and  rapidity 
of  their  pathogenic  activity.  Chief  of  these  micro-organisms,  from  t  he  standpoint 
of  coinmunicability,  is  anthrax.  In  the  same  class,  though  not  as  readily  communi- 
cable, we  may  add  tetanus,  malignant  edema,  and  the  so-called  gas  bacillus  infection 
of  Welch;  the  latter,  if  communicable  at  all,  occurring  through  contact  with  con- 
taminated earth  conveyed  to  an  open  wound. 

Disinfection  against  and  precautions  involved  in  the  care  of  patients  suffering 
from  any  of  this  second  group  of  infections  are  so  wholly  within  the  province  of  the 
medical  profession  that  we  would  hardly  seem  warranted  in  giving  them  adminis- 

425 


426  OPERATION"    OF   THE   HOSPITAL 

trative  attention  except  under  special  medical  direction  in  each  individual  case. 
We  shall,  therefore,  give  no  further  consideration  to  this  group  in  this  section. 
There  are  some  very  radical  differences  between  the  various  classes  of  infections 
that  we  have  characterized  as  members  of  the  first  group,  not  only  in  their  pathology, 
cause,  course,  and  chief  characteristics — they  differ  quite  as  materially  from  the 
standpoint  of  their  communicability  and  the  avenues  through  which  they  may  be 
transmitted.  Perhaps  it  will  be  better  if  we  take  up  these  various  classes  of  com- 
municable diseases  and  view  them  in  a  many-sided  way  for  purposes  of  isolation 
and  disinfection. 

DISEASES  OF  CHILDHOOD 

Let  us  first  consider  the  eruptive  fevers  of  childhood  and  mumps,  whooping- 
cough,  and  diphtheria. 

Diphtheria  is  primarily,  in  most  cases,  localized  or  rather  manifest  in  the  pharynx, 
nasopharynx,  and  larynx.  The  bacillus  of  diphtheria  is  also  found  in  the  discharges 
from  the  ears,  nose,  and  other  mucous  membranes,  and  sometimes  on  the  skin. 

While  we  do  not  know  the  exact  etiology  of  the  eruptive  fevers,  reasoned  by 
analogy  it  may  be  assumed  that  they  are  of  micro-organic  origin.  The  skin  is  the 
seat  of  their  chief  activity,  although  in  many  of  the  eruptive  diseases  the  skin  erup- 
tion (exanthem)  is  preceded  by  an  eruption  on  the  internal  mucous  surfaces.  The 
so-called  exanthem,  the  Koplik  spots  in  measles,  and  the  ocular  and  nasal  catarrhs, 
are  characteristic  in  all  of  the  eruptive  fevers.  Mumps  and  whooping-cough  are 
likewise  of  unknown  bacterial  origin,  and  no  specific  micro-organism  for  them  has 
been  identified,  but  they  undoubtedly  are  communicable  by  way  of  the  nose  and 
throat  discharges;  so  it  will  be  necessary,  if  we  are  to  take  an  efficient  measure  of 
precaution  against  the  spread  of  these  diseases,  that  we  institute  an  isolation  which 
shall  be  at  once  effective  and  consistent. 

Before  we  set  the  machinery  in  motion  for  the  complete  isolation  of  contagious 
cases,  let  us  recall  what  takes  place  in  the  admission  rooms  of  the  institution. 

IN  THE  EXAMINING  ROOM 

The  patient,  usually  a  child,  is  brought  to  the  admission  room.  Perhaps  the 
examiner  has  been  able  to  make  a  diagnosis  at  once,  due  to  the  complete  develop- 
ment of  the  disease,  and  he  pronounces  it  a  communicable  infection. 

We  are  confronted  with  an  embarrassing  situation  at  the  outset,  one  with  which 
we  shall  have  to  deal  expeditiously  and  without  regard  to  sentiment.  Most  hospi- 
tals do  not  admit  known  infectious  diseases,  and  the  patient  must  be  rejected. 
The  child  has  been  conveyed  to  the  hospital  in  the  street  car  or,  perhaps,  in  a  pub- 
he  conveyance.  In  the  large  cities  where  there  is  an  efficient  sanitary  regime  it 
would  be  a  punishable  offence  to  allow  the  child  to  be  returned  home  the  way  it 
came,  and  thus  expose  others.  In  smaller  communities  where  there  is  no  specific 
law  to  punish  the  offender  the  moral  responsibility  of  an  institution  pledged  to  safe- 
guard the  health  of  the  people  is  even  greater,  because  the  community  is  not  able 
to  protect  itself. 

The  child  must  be  detained  in  the  examining  room  with  its  mother  or  whoever 
accompanied  it.  If  it  is  in  a  large  city,  the  health  department  will  send  an  ambu- 
lance and  take  mother  and  child  to  some  municipal  institution  for  isolation  and  the 
care  of  the  patient.  If  it  is  in  a  small  town  where  there  are  no  constituted  authori- 
ties, some  sort  of  vehicle  must  be  pressed  into  service  that  can  be  subjected  to  care- 


ISOLATION    AND   DISINFECTION  U7 

ful  fumigation  at  the  journey's  end.     Fumigation  tnusl  be  quite  as  eflBcienl  as  thai 

which  would  be  prescribed  for  a  habitation  that  had  harbored  an  infected  ease. 

The  examining  room  must  be  immediately  closed  against  all  other  patient-, 
thoroughly  fumigated,  and  left  sealed  for  at  least  twenty-four  hours  before  being 
used  again. 

The  ease  must  be  followed  to  its  destination,  and  the  proper  machinery  se1  in 
motion  for  the  isolation  of  the  patient.  The  sanitary  bureau  must  be  notified  or, 
in  the  absence  of  such  an  institution,  the  proximity  of  the  disease  should  in  some 
manner  receive  publicity. 

But,  perhaps,  it  is  designed  to  admit  the  patient;  or  it  may  be  that  the  trans- 
missible character  of  the  disease  is  only  suspected,  and  the  child  too  ill  to  be  sent 
away;  or,  as  often  occurs,  the  virulency  of  the  disease  is  recognized,  though  the 
patient  is  in  extremis,  in  which  case  no  institution  would  be  justified  in  refusing  its 
hospitality. 

Then  there  are  cases  that  develop  in  the  institution  after  admission,  perhaps 
after  the  routine  observation  period  has  passed,  and  the  patient  has  been  assigned 
to  the  ward  with  other  children.  In  such  a  case  we  have  not  only  to  isolate  the 
afflicted  patient,  but  we  must  at  once  perform  a  very  active  duty  to  the  children 
exposed. 

Care  of  the  Exposed. — It  is  not  enough  that  we  remove  the  infected  patient ; 
we  must  immediately  remove  the  other  children  from  the  room,  give  them  a  disin- 
fecting bath,  including  hair,  face,  and  hands,  reclothe  them  in  clean  apparel,  and 
put  them  into  other  quarters  isolated  from  the  other  patients  of  the  hospital.  The 
room  in  which  the  exposure  occurred  must  be  washed  down,  sealed,  and  fumigated 
in  some  such  manner  as  shall  be  hereafter  discussed. 

We  have  now  the  child  suffering  from  a  transmissible  disease,  and  our  duty  is 
so  exacting  and  precise  that  in  most  carefully  conducted  institutions  it  rises  to  the 
dignity  of  a  definite  technic. 

There  should  be  grades  of  isolation,  each  disease  being  considered  by  itself,  the 
degree  and  character  of  the  isolation  depending  on  the  supposed  avenue  of  com- 
munication and  the  virulence  and  danger  of  the  disease  when  once  contracted. 
For  instance,  Koplik,  of  Mt.  Sinai  hospital,  prescribes  what  he  calls  a  "constructive" 
isolation  for  gonorrheal  vaginitis  in  infants,  scarlet  fever,  and  measles.  This 
isolation  allows  the  patient  to  occupy  a  bed  in  the  ward,  separated  from  the  other 
patients  by  a  tape-line  suspended  from  portable  posts  with  broad  bases.  The 
effectiveness  of  this  "constructive"  isolation  depends  upon  the  conscientiousness 
with  which  the  nurse,  intern,  and  attending  physician  don  gown  and  gloves  before 
going  inside  the  dead  line  of  half-inch  tape.  Precautions  must  lie  taken  so  that  the 
individual  belongings  of  the  patient  will  not  be  used  for  other  occupants  of  the  ward. 
Some  of  us  who  have  tried  this  form  of  isolation  have  not  been  so  successful  as  it- 
exponent. 

It  has  been  suggested  by  other  excellent  men  that  scarlet  fever  may  be  isolated 
behind  a  screen  in  the  general  ward,  effectiveness  here  also  being  dependent  on  the 
care  of  attendants  in  using  gown  and  gloves;  and  there  is  no  question  that  cases  oi 
scarlet  fever  have  run  their  course  under  such  isolation  without  spreading  to  a  single 
other  patient.  But  this  jeopardizes  a  ward  full  of  sick  children  with  a  minimum 
rather  than  a  maximum  of  precaution. 

There  are  surgeons  who  affirm  their  willingness  to  hazard  a  postoperative  case 
in  a  ward  with  erysipelas,  merely  taking  the  precaution  to  have  a  separate  nurse 
for  the  erysipelas  patient  or  to  insis!  on  separate  gown  and  gloves.  Usually  the 
surgeon's  reliance  on  the  sufficiency  of  such  isolation  is  confined  to  ward  patient-. 


428  OPERATION    OF    THE    HOSPITAL 

however,  and  does  not  extend  to  his  private  cases,  while  the  hospital  administrator 
must  deal  with  the  infection  and  not  with  the  importance  of  the  patient  affected. 

There  is  a  scientific  debate  as  to  the  transmissibility  of  pulmonary  tuberculosis 
by  indirect  contact,  as  usually  exists  between  patients  in  the  wards  of  a  hospital; 
the  transmissibility  of  pneumonia  under  like  conditions  is  also  unsettled.  Isola- 
tion, if  instituted,  should  be  complete  and  in  all  details  should  be  consistent.  The 
same  is  true  of  typhoid  fever,  supposed  by  many  to  be  communicable  only  through 
the  excreta  of  the  gastro-intestinal  tract;  but  many  of  us  have  seen  cases  of  typhoid 
develop  in  wards  where  typhoid  fever  patients  were  being  treated.  It  may  be 
barely  possible  that  there  are  other  avenues  of  communication — the  nurse's  or  doc- 
tor's hands  may  convey  the  infection  to  another  patient  suffering  from  some  other 
disease  or  convalescing  from  some  illness.  It  is  possible  to  conceive  that  the  ex- 
aminer's or  attendant's  hands  may  gather  up  micro-organisms  from  the  external 
surfaces  of  the  body. 

There  are  numerous  well  authenticated  cases  where  infection  has  been  carried 
from  one  person  to  another  in  a  hospital  ward  through  the  medium  of  the  house- 
fly, as  well  as  the  slower,  but  equally  treacherous  bed-bug,  where  these  are  allowed 
to  persist.  In  some  experiments  made  with  the  house-fly  recently  it  was  found  that 
a  single  fly,  marked  for  identification,  had  visited  a  great  number  of  wards  and  rooms, 
as  well  as  the  hospital  kitchen,  in  the  course  of  a  few  hours.  We  need  not  cite  the 
cases  of  the  mosquito,  which  has  been  identified  as  practically  the  sole  carrier  of 
yellow  fever,  the  Texas  tick  as  the  carrier  of  Texas  fever,  so  common  among  the 
cattle  of  the  south,  and  the  rat  flea  as  the  carrier  of  the  plague. 

If  we  have  diverged  from  our  text  of  complete  isolation,  the  digression  may  not 
be  unprofitable  if  we  have  resolved  that  even  where  the  "doctors  disagree"  we 
will  not  let  the  patient  die  by  any  remissness  on  our  part  when  the  remedy  is  at 
hand. 

COMPLETE  ISOLATION 

Complete  isolation  is  the  care  of  a  patient  so  far  removed  from  all  other  persons 
excepting  the  nurse  that  there  can  be  no  communication  by  any  avenue  whatsoever 
— either  by  means  of  currents  of  air  wafting  skin  scales,  or  by  the  house-fly,  mosquito, 
or  other  insects;  or  through  the  drinking-water  or  sewage,  or  by  means  of  the  linens, 
or  the  dishes,  or  the  cutlery.  No  effective  isolation  can  be  carried  out  if  a  nurse  or 
intern,  or  orderly,  or  floor  man,  or  housemaid  is  employed  at  any  point  where  they 
have  access  to  or  can  possibly  come  into  contact  with  anything  used  for  or  by  the 
patient.  No  physician,  nurse,  or  employee  should  be  allowed  to  perform  duties  in 
any  other  place  after  having  been  in  contact  with  a  contagious  case.  It  is  often 
not  feasible  in  a  general  hospital  to  isolate  an  intern  as  well  as  a  nurse,  and  in  a  good 
many  institutions  it  is  the  custom  to  dispense  entirely  with  the  services  of  an  intern, 
and  to  leave  the  medical  attention  to  a  responsible  member  of  the  visiting  staff,  one 
who  will  be  sure  to  take  all  proper  precaution  against  carrying  the  infectious  matter 
away  from  the  patient's  quarters. 

It  may  be  very  seriously  doubted  if  efficient  isolation  can  be  practised  in  quar- 
ters under  the  same  roof  where  other  people  are  housed,  and  especially  if  some  of 
these  are  acutely  ill  with  other  diseases,  and,  in  consequence,  suffering  from  a  low- 
ered resistance. 

Separate  Building  for  Isolation. — There  should  be  a  separate  building  for  the 
care  of  patients  suffering  from  the  communicable  diseases.  It  does  not  make  much 
difference  what  kind  of  a  building  it  is,  so  it  is  clean  and  comfortable  and  located  at 
least  several  hundred  feet  from  other  habitations,  and  provided  with  good  screens 


isolation-   AND   DISINFECTION  429 

and  the  simplest  utensils  and  apparatus.  A  knock-down  house  that  can  be  burned 
when  necessary  is  an  ideal  place  in  which  to  segregate  a  contagious  case  or  cases. 
One  of  the  very  best  provisions  is  a  tent  thai  can  be  kerosened  and  burned  into  the 
ground.  The  tent  ought  to  have  a  plain  board  floor,  raised  a  foot  above  the 
ground,  with  the  earth  hilled  up  around  the  outside  so  that  moisture  cannot  find  its 
way  underneath.  There  should  be  a  frame  for  the  canvas,  made  of  two-by-fours. 
A  thimble  can  be  sewed  into  one  side  of  the  tent  for  the  stove-pipe,  and  an  ordinary 
hot-air  stove  can  be  used,  or,  better  still,  a  Sibley  or  tent  stove  made  to  set  in  a  deep 
box  of  sand  on  the  floor. 

If  the  patient  and  nurse  are  to  be  served  with  meals  from  the  institution  kitchen 
and  with  linens  from  the  common  linen  room  or  laundry,  at  least  three  large  pails 
or  garbage  cans  will  be  required,  one  for  the  soiled  dishes  and  cutler}-,  one  for  the 
soiled  linens,  and  one  for  the  garbage.  All  of  these  must  have  tight  covers,  and  there 
must  be  plenty  of  water  available  in  which  to  soak  the  things.  The  cans  may  set 
outside  the  door  or  under  a  porch  if  there  is  one.  The  things  should  be  put  in  at 
night  before  the  nurse  retires,  and  a  2\  to  5  per  cent,  carbolic  acid  solution  should 
be  used.  The  other  things  should  soak  over  night,  and,  if  faithfully  done,  no 
micro-organism  except  the  spore-bearers  can  live.  After  the  linens  are  put  in 
the  can  and  the  carbolic  solution  is  added  and  the  lid  fitted  on,  the  nurse  should 
give  the  can  a  violent  shaking,  so  that  some  of  the  solution  will  wash  over  every 
possible  point.  The  same  can  be  done  with  the  dishes,  care  being  taken  not  to  break 
them.  The  next  morning  the  hospital  orderly  may  with  perfect  safety  gather  up 
the  things  and  take  them  wherever  they  belong. 

Just  one  more  precaution  must  be  taken:  the  nurse,  after  placing  the  things  in 
the  cans,  must  lift  the  lid  by  the  handle  and  set  it  in  place;  and  in  order  to  shake 
the  can  so  that  the  solution  may  come  in  contact  with  all  parts  of  the  inside  she 
will  have  to  lay  one  hand  on  the  side  of  the  can  and  with  the  other  hold  the  handle. 
In  this  act  she  may  infect  the  handle  and  the  whole  outside  of  the  can;  so  she  must 
be  instructed  either  to  wear  gloves  for  this  duty  or  to  wrap  each  hand  in  a  sterile 
towel. 

The  linens  ami  dishes,  after  removal  from  the  cans,  should  be  washed  separately 
from  everything  else,  so  that  the  odor  of  carbolic  acid  wall  not  cling  to  other  linens 
or  other  dishes. 

Before  the  patient  enters  the  isolation  quarters  she  should  have  been  supplied 
with  everything  that  by  any  chance  may  be  required — dressings,  instruments, 
utensils,  towels,  soap,  and  medicines.  The  nurse  should  lay  in  a  supply  of  stores 
when  she  assumes  charge  of  the  case. 

Of  course,  supplies  may  be  left  on  the  stoop  from  time  to  time,  and  visitors  may 
be  allowed,  under  proper  precautions,  to  talk  with  the  nurse  or  patient  from  a  little 
distance,  but  always  from  a  point  "up  the  wind."  Reading  matter  should  be  care- 
fully selected  with  a  view  to  its  destruction  at  the  end  of  the  case.  Some  authori- 
ties say  books  may  be  fumigated  by  hanging  them  over  a  line  in  the  room  and  sub- 
jecting them  to  formalin  fumes.  It  may  be  safely  doubted  whether  the  risk  is  a 
safe  one,  especially  in  these  days  when  reading  matter  is  so  cheap. 

RAISING  THE  QUARANTINE 

On  the  termination  of  the  case,  as  expressed  by  the  attending  physician,  it  is 

imperative  that  the  nurse  and  patient  take  every  precaution  to  remove  infectious 
material  from  the  person  before  they  leave  the  infected  quarters.  It  is  not  suffi- 
cient to  give  them  the  prescribed  bath  and  allow  the  change  of  wearing  apparel 


430  OPERATION    OF   THE    HOSPITAL 

in  the  infected  rooms.  A  bath-room  adjacent  to  the  sick  quarters  should  be  pro- 
vided, or,  when  this  is  impossible,  a  small  tent  or  portable  room  may  be  erected 
just  outside,  and  complete  change  of  clothing  for  patient  and  nurse  provided. 
The  room  should  contain  two  tubs  of  warm  bichlorid  water  of  a  strength  of  1 :  10,000. 
The  nurse  may  wash  the  patient's  hair  in  the  same  strength  of  bichlorid  water — 
this  may  be  done  before  leaving  the  infected  rooms,  especially  if  the  patient  is  a  girl 
or  woman  with  a  great  deal  of  hair  that  cannot  be  washed  by  the  patient  herself; 
the  head  may  be  tied  up  in  a  sterile  towel. 

Then  the  patient,  leaving  infected  clothes  behind,  should  step  to  the  impro- 
vised bath-room,  scrub  herself  thoroughly,  put  on  the  clean  apparel,  and  leave  the 
place.  If  a  child  is  to  be  bathed  and  reclothed,  the  nurse  may  perform  this  office 
after  slipping  on  a  sterile  gown  and  gloves.  After  the  patient  has  received  attention, 
the  nurse  should  go  through  the  same  performance  for  herself,  and  leave  the 
quarters. 

It  will  be  well  if  the  bath  waters  are  left  for  twenty-four  hours,  or  at  least  twelve, 
in  order  that  the  bichlorid  may  destroy  whatever  infectious  matter  may  have  been 
left  in  the  water.  Then  a  careful  person  in  sterile  gown  and  gloves  should  dispose 
of  the  water  where  it  cannot  be  got  at  by  man  or  beast.  Wash  the  tubs  in  a  3  or 
5  per  cent,  carbolic  acid  solution  and  begin  fumigation;  the  bath-room  should  also 
be  subjected  to  the  process  in  the  manner  which  shall  be  hereafter  prescribed. 

TUBERCULOSIS  AND  PNEUMONIA 

There  need  be  very  little  difference  in  the  isolation  of  pulmonary  tuberculosis 
and  pneumonia.  Isolation  in  each  of  these  will  be  performed  in  a  fairly  practicable 
and  efficient  manner  if  we  prevent  the  dissemination  of  sputum,  saliva,  and  blood 
ejected  from  the  air-passages.  The  best  procedure  is  to  gather  this  ejected  matter 
immediately  after  it  leaves  the  patient's  mouth  or  nose,  so  that  it  can  be  destroyed. 
For  this  purpose  sputum  cups  with  springs  for  automatically  opening  and  closing 
the  cups  may  be  employed.  If  handkerchiefs  are  used  they  should  be  soaked  in  a 
2|  per  cent,  carbolic  acid  solution  for  at  least  twelve  hours  after  they  are  discarded 
by  the  patient;  gauze  strips  used  for  wiping  the  patient's  mouth  and  nose  should 
be  burned.  Drinking-cups,  glasses,  and  dishes  used  by  these  patients  should  be 
disinfected  in  a  2\  per  cent,  carbolic  solution  for  at  least  twelve  hours  or  boiled  for 
at  least  one  hour.  Some  patients  suffering  from  either  of  these  infections  are  too 
ill  to  aid  in  the  precautions  indicated,  and  insist  upon  expectorating  on  the  floor, 
bed-clothing,  and  elsewhere;  in  these  cases  it  is  imperative  to  set  up  a  complete  iso- 
lation. We  know  that  the  tubercle  bacilli  coughed  up  from  patients'  lungs  are 
usually  encapsulated  in  a  coating  of  mucus.  This  mucous  capsule  in  drying  or 
under  heat  often  becomes  extremely  hard  and  forms  a  shell  about  the  bacillus, 
rendering  it  very  difficult  to  destroy.  Thus,  while  a  tubercle  bacillus  grown  in  a 
culture-medium  may  be  very  easily  destroyed  under  a  heat  of  say  60°  C.  for  twenty 
minutes,  the  same  bacillus  when  encapsulated  will  sometimes  resist  a  boiling  tem- 
perature for  a  very  much  longer  period. 

Unfortunately,  patients  suffering  from  pneumonia  are  oftentimes  delirious 
and  cannot  help  in  their  own  isolation.  Sufferers  from  pulmonary  tuberculosis 
are  decided  optimists,  imagining  that  they  are  about  well;  even  when  in  a  dying 
condition  it  is  almost  impossible  to  make  them  understand  the  necessity  of  isolation 
from  well  people.  Thus  even  under  favorable  circumstances  there  ought  to  be 
pneumonia  wards  set  apart  specifically  for  that  disease  in  a  hospital,  and  there 
ought,  by  all  means,  to  be  wards  set  apart  for  pulmonary  tuberculosis. 


ISOLATION'    AND    DISINFECTION  13] 

We  arc  not  quite  certain  that  other  pneumococcus  infections,  such  as  meningitis, 
are  communicable,  but  a  feeling  is  becoming  prevalent  in  the  medical  profession 

that  any  disease  that  originates  from  the  pneumococcus  is  a  dangerous  disease  to 
be  brought  in  contact  with  well  people.  We  know  that  a  good  many  children 
are  attacked  by  pneumonia;  then  a  purulent  pneumococcus  pleurisy  may  develop, 
and  finally  these  same  children  may  be  attacked  by  a  meningitis,  the  spinal  fluid 
being  filled  with  the  pneumococci.  Pneumonia  is  a  blood  infection,  a  pneumococcus 
bacteremia;  thus  we  are  not  certain  from  the  very  inception  of  the  disease  that  the 
micro-organisms  will  not  pervade  other  tissues,  as  the  upper  respiratory  passages, 
the  meninges,  the  bones,  joints,  and  even  the  peritoneum. 

On  the  other  hand,  tuberculous  affections  elsewhere  than  of  the  lungs  require 
little  precaution  against  communication.  Sometimes  joints  break  clown  and  pus 
infections  follow,  but  the  micro-organisms  in  these  cases  are  confined  pretty  well 
to  the  pus  and  dressings  of  the  patient  and  are  easily  destroyed.  It  is  hardly  cred- 
ible that  tuberculous  pus  infectious  matter  could  do  very  much  harm  in  an  institu- 
tion when  ordinary  care  is  taken  in  the  destruction  of  the  excreta,  dressings,  pus- 
basins,  and  where  the  ordinary  laws  of  cleanliness  are  observed. 

TYPHOID  FEVER 

There  seems  to  be  a  growing  opinion  in  the  medical  profession  that  typhoid 
patients  ought  to  be  completely  segregated  in  the  hospital  from  patients  suffering 
from  all  other  diseases,  and  that  this  segregation  should  continue  at  least  until 
convalescence  is  well  advanced.  There  should  be  distinct  typhoid  wards  sufficient 
in  number  and  size  to  accommodate  all  the  patients  of  different  classes;  private 
patients  may  be  segregated  in  rooms  of  one  or  more  beds.  In  any  event,  each 
patient  should  have  individual  belongings  of  every  description  kept  separately, 
excepting  perhaps  dishes,  and  these  should  be  soaked  after  use  for  at  least  twelve 
hours  in  a  3  per  cent,  carbolic  acid  solution. 

The  other  equipment,  individual  in  character,  will  comprise  a  long  list  of  articles 
adequate  for  the  purpose. 

Typhoid  Equipment 

1  large  can  for  feces,  urine,  and  used  sponge  waters. 

1  can  for  bed-pans  and  urinals. 

1  can  for  used  linens. 

1  large  sponge  basin. 

1  compress  basin. 

1  dressing  basin. 

1  pus-basin  for  bedside. 

2  large  sponges. 

1  rubber  coat,  gown,  or  apron  for  nurse. 
1  bath  blanket. 

1  bath  thermometer. 

2  sets  of  stupes. 

1  enema  set,  including  small  rubber  sheet. 

1  rectal  tube  and  funnel. 

Note. — Sterilizers  for  feces,  urines,  sponge  waters,  and  excreta  of  all  kinds 
emanating  from  typhoids  must  be  used  instead  of  cans  in  tin-  progressive  day. 
Such  sterilizers  are  described   under  the  equipment    section  cm  Sterilizers. 


432  OPERATION    OF   THE    HOSPITAL 

Assuming  that  the  typhoid  patient  occupies  a  bed  in  a  single  room  or  in  a  ward 
where  there  are  none  others  excepting  typhoid  patients,  it  will  not  be  difficult  to 
take  the  necessary  precautions  against  infection  of  other  patients  by  direct  contact. 
The  nurse  will  necessarily  care  for  only  typhoid  patients,  and  she  will  do  so  while 
wearing  gown  and  gloves,  or  at  least  when  she  leaves  the  quarters  she  will  so  effect- 
ively cleanse  her  hands  that  there  will  be  little  likelihood  of  carrying  the  infection, 
especially  if  she  has  used  a  gown  and  head-cloth  during  her  hours  of  duty. 

The  only  elements  of  danger,  therefore,  seem  to  be  the  excreta,  bath-water, 
and  contamination  by  dishes,  linens,  and  used  material  intended  to  be  thrown  away. 

Dishes,  drinking  glasses,  and  cutlery  should  either  be  kept  for  the  patient  indi- 
vidually and  confined  to  patient's  quarters,  or  should  be  boiled  each  day  before 
being  sent  back  to  the  kitchen,  or,  better  still,  they  should  be  soaked  in  a  3  per  cent, 
carbolic  acid  solution  over  night.  Stools  should  be  disinfected  for  at  least  six  hours 
in  a  2|  per  cent,  carbolic  acid  solution,  the  quantity  of  carbolized  water  being  the 
same  in  amount  as  the  stool.  Urines  should  be  disinfected  for  at  least  six  hours  in 
a  1  :  1000  bichlorid  solution,  equal  parts  urine  and  solution.  Linens  should  be 
soaked  for  at  least  twelve  hours  in  a  2§  per  cent,  carbolic  acid  solution,  and  then 
rinsed  in  clear  water  before  being  sent  to  the  laundry  for  further  washing.  Bed- 
pans, urinals,  and  basins  should  be  kept  in  the  cans  provided  for  the  purpose  in  a 
2|  per  cent,  carbolic  acid  solution  or  boiled. 

There  are  now  in  use  in  the  slop-rooms  off  each  typhoid  ward  in  most  large  insti- 
tutions special  sterilizers  for  the  destruction  of  materials  infected  with  typhoid — 
one  for  linens,  one  for  utensils,  including  the  stool  and  urine,  vomitus,  and  con- 
tents of  pans  and  basins.  These  sterilizers  are  described  more  in  detail  under  the 
section  on  Equipment  of  the  Hospital. 

ERYSIPELAS 

Erysipelas  is  a  streptococcus  infection,  of  which  there  are  two  forms — the 
traumatic,  which  attacks  a  wounded  surface,  and  the  idiopathic  form,  which  attacks 
an  apparently  unbroken  skin  surface,  although  in  these  cases  there  is  undoubtedly 
a  microscopic  abrasion.  There  are  other  diseases  or  manifestations  that  seem  to 
belong  to  the  same  family,  and  are  equally  infectious  and  equally  harmful,  namely, 
the  phlegmons,  the  so-called  lymphangitis,  and  some  of  the  forms  of  cellulitis. 
These,  if  not  identical,  are  so  closely  related  to  erysipelas  that  the  terms  are  almost 
indifferently  used  by  many  surgeons.  Some  surgeons  are  disposed  to  class  them  as 
non-transmissible,  but  many  hospital  administrators  have  permitted  lymphan- 
gitis and  phlegmonous  cases  in  the  surgical  wards  of  the  hospital  only  to  find 
themselves  in  the  midst  of  an  erysipelas  epidemic  in  a  few  days.  Among  those 
who  are  best  posted  concerning  the  character  of  these  inflammations  it  is  assumed 
that  any  one  of  them  is  sufficiently  communicable  and  sufficiently  harmful  in  the 
surgical  wards  of  a  hospital  to  warrant  immediate  removal  and  complete  isolation. 
There  is  no  doubt  that  erysipelas  in  any  of  its  forms  is  one  of  the  most  virulent  in- 
fections that  can  come  into  an  institution,  and  its  power  for  harm,  once  there,  is 
almost  without  limit.  In  fact,  there  are  many  excellent  authorities  who  fear  ery- 
sipelas much  more  than  any  other  communicable  disease.  So  that  in  prescribing 
a  line  of  conduct  for  meeting  the  appearance  of  a  case  of  erysipelas  it  should  be  very 
strongly  urged  that  complete  isolation  in  the  way  prescribed  heretofore  is  the  only 
efficient  manner  in  which  to  dispose  of  this  disease. 


ISOLATION   AND   DISINFECTION  433 


CEREBROSPINAL    MENINGITIS 


Epidemic  cerebrospinal  meningitis  is  not  nearly  so  formidable  a  disease  now 

as  it  was  a  few  years  ago.  We  know  that  the  epidemic  form  of  cerebrospinal 
meningitis  is  caused  by  a  micro-organism — the  meningococcus,  a  non-spore-bearer 
not  very  difficult  to  destroy  and  one  whose  origin  in  the  body  is  difficult  to 
trace.  The  infection  which  it  causes  has  always  remained  in  more  or  less  mys- 
tery, that  is,  the  avenues  of  contact  in  an  epidemic  of  cerebrospinal  meningitis 
have  not  been  quite  well  understood.  When  there  is  an  epidemic  of  typhoid 
fever  we  can  generally  trace  the  infection  to  bad  water  or  to  some  other  equally 
positive  avenue  of  communication,  and  so  with  a  good  many  of  the  definite  infec- 
tions, but  it  is  not  at  all  the  case  with  the  epidemic  meningitis.  Some  epidemics 
are  very  mild  and  some  so  severe  that  most  of  the  patients  die.  In  some  epidemics 
the  patients  live  for  considerable  periods  of  time — days  or  even  weeks — but 
eventually  the  disease  culminates  fatally  in  a  great  many  of  them.  Again,  the 
patients  will  die  almost  within  a  few  hours  after  the  onset.  The  symptoms  vary 
in  individual  cases  and  with  different  epidemics.  While  there  has  been  a  great  deal 
of  speculation  on  the  part  of  scientists,  hygienists,  and  sanitary  experts,  as  well  as 
pathologists,  no  one  has  offered  any  reasonable  explanation  of  the  manner  in  which 
the  disease  is  transmitted. 

The  pathologists,  as  a  rule,  are  rather  disposed  to  disavow  communicability 
between  a  patient  suffering  with  this  infection  and  a  well  person,  and  at  the  same 
time  they  advise  a  pretty  rigid  isolation;  until  something  more  is  known  about  the 
disease  and  its  mode  of  communication,  institution  administrators  are  hardly  doing 
their  full  duty  without  taking  ample  precautions  for  the  segregation  of  sufferers 
from  this  infection.  During  epidemics  it  may  be  that  wards  can  be  set  apart  for 
these  patients;  at  other  times  the  patients  in  small  groups  of  one  or  two  may  be 
segregated  in  private  rooms  or  in  very  small  wards.  Rigid  disinfection  should  be 
practised  in  disposing  of  the  discharges  from  the  air-passages  and  from  the  skin. 
The  linens,  bath-water,  and  all  contaminated  material  should  receive  attention. 

The  weight  of  authority  seems  rather  to  lie  in  the  presumption  that  the  micro- 
organism emanates  from  the  air-passages  and  pervades  the  atmosphere  during  the 
time  of  an  epidemic,  and  that  it  is  carried  from  a  sick  person  to  a  well  one. 
Whatever  form  of  isolation  is  practised  should  provide  for  a  rigid  cleanliness  of  the 
body  of  the  patient  and  attendants,  so  that  infected  particles  may  not  be  carried 
through  the  atmosphere. 

The  disease  itself  has  been  to  a  great  extent  brought  under  control  since  the 
creation  of  an  antimeningitis  serum.  This  serum  is  not  given  to  prevent  the  dis- 
ease, but  to  effect  a  cure  where  it  actually  exists.  The  technic  for  its  use  is  so 
thoroughly  within  the  province  of  the  medical  profession  that  it  should  always  be 
given  under  strict  medical  direction. 

GONORRHEA 

Most  general  hospitals  do  not  accept  patients  suffering  from  active  gonorrhea, 
and  the  type  of  that  disease  most  frequently  met  in  the  institution  is  that  which 
manifests  itself  as  a  gonorrheal  vaginitis  in  children,  especially  infants.  The 
micro-organism  itself  is  one  of  the  most  difficult  to  grow  artificially.     It  has  little 

or  no  vitality,  and  dies  in  the  open  air  in  a  very  short  time.     This  micro-organism 
infests  the  crypts  and  folds  of  the  urethra  and  vagina,  and  it   is  as  difficull   to  dis- 
lodge as  it  is  to  reach  with  destructive  agents. 
•28 


434  OPERATION   OF   THE    HOSPITAL 

The  laboratory  finds  no  difference  between  the  micro-organism  that  causes 
gonorrhea  in  the  adult  and  that  form  found  in  the  vaginitis  of  infants,  but  it  is  a 
well-known  fact  that  there  are  clinical  differences  between  the  two.  For  instance, 
medicolegal  literature  is  replete  with  cases  of  gonorrhea  contracted  by  small 
children  during  rape  at  the  hands  of  an  adult  suffering  from  the  disease,  and  the 
disease  when  attacking  these  children  is  most  virulent  in  its  form  and  places  the 
patient  in  jeopardy  of  her  life.  The  inflammation  is  intense,  the  invasion  of  the 
infection  tremendous,  and  oftentimes  the  infection  has  found  its  way  into  the 
Fallopian  tubes,  setting  up  a  fatal  peritonitis.  Whereas  the  vaginitis  contracted 
by  one  small  child  from  another  in  the  wards  of  the  hospital  or  in  the  homes  of  the 
poor  is  a  vastly  different  matter.  It  is  almost  passive  in  form;  the  discharge  may 
be  profuse,  or  at  times  is  very  slight  or  intermittent,  but  it  is  appalling  to  hospital 
administrators  everywhere  by  its  persistency  and  the  difficulty  with  which  it  may 
be  stopped  short  of  infecting  every  child  in  the  ward  where  it  once  obtains  a  footing. 

Complete  isolation  is  the  only  effective  way  to  prevent  house  epidemics  and 
ward  infections. 

It  is  claimed  by  some  hospital  administrators  that  careful  segregation  of  patients 
and  provision  for  supplying  each  patient  with  individual  belongings  in  the  wards 
of  a  hospital  tends  to  prevent  the  spread  of  infection.  Those  who  have  had  wide 
experience  do  not  agree  with  this  view,  and  insist  upon  immediate  removal  of  chil- 
dren suffering  from  gonorrheal  infection. 

The  wide  prevalence  of  gonorrheal  vaginitis  seems  to  have  set  a  new  problem 
for  laboratory  men,  and  even  they  seem  at  a  loss  to  account  for  the  long  incubation 
periods.  Children  have  remained  in  hospitals  for  a  month  or  more  with  no  reason- 
able explanation  advanced  as  to  how  the  infection  occurred.  The  question  has 
arisen,  and  it  is  not  yet  settled,  whether  the  incubation  period  has  been  so  long, 
whether  the  disease  was  contracted  for  the  first  time  by  some  apparently  inconceiv- 
able process,  or  whether  it  had  the  faculty  of  remaining  latent  in  the  crypts  and 
folds  for  an  indefinite  period.  At  any  rate,  the  common  experience  with  the  disease 
seems  to  call  for  a  more  complete  isolation  than  for  almost  any  other  disease  of 
childhood. 

The  adult  variety  of  gonorrhea  seems  a  vastly  different  thing,  and  ordinary 
precautions  seem  to  be  sufficient  to  prevent  its  spread,  either  from  one  patient 
to  another  or  from  a  patient  to  an  attendant. 

The  disinfection  of  dishes,  linens,  and  the  belongings  of  patients  suffering  from 
gonorrheal  vaginitis  should  be  complete  if  the  articles  are  soaked  in  a  2|  per  cent, 
carbolic  acid  solution  over  night. 

SYPHILIS 

The  avenues  by  which  syphilis  is  communicated  and  the  infections  produced  are 
quite  definitely  understood.     They  are: 

(1)  Direct  contact  of  a  syphilitic  ulcer  or  primary  sore  arising  from  the  surface 
of  an  infected  person  with  denuded  skin  or  mucous  membrane  of  a  well  person; 
this  means  acquiring  the  infection  during  cohabitation  or  in  the  act  of  kissing. 

(2)  Contact  of  a  denuded  mucous  membrane  or  skin  surface  of  a  well  person 
with  an  area  that  has  been  contaminated  or  infected  by  sufferers  from  an  active 
syphilis;  this  means  the  contraction  of  the  disease  from  a  privy-seat  or  from  a  drink- 
ing-cup. 

(3)  The  use  of  towels  or  bed  linen  by  a  well  person  that  have  been  used  by  a 
sufferer  from  an  active  syphilis. 


ISOLATION   AND   DISINFECTION  435 

(4)  Contact  which  occurs  when  people  sleep  together;  the  body  of  a  well  person 
comes  in  contact  with  the  skin  of  a  sufferer  from  syphilis  and  so  acquires  the 
disease. 

(5)  By  heredity — one  or  both  parents  may  be  syphilitic. 

We  will  notice  that  all  of  these  avenues  of  communication  are  either  by  direct 
contact  of  an  infected  person  with  a  well  person,  or  by  a  very  close  form  of  indirect 
contact,  through  the  medium  of  an  infected  surface. 

In  attempting  to  isolate  a  sufferer  from  syphilis  we  may  neglect  the  possibility 
of  any  communication  through  the  wafting  of  particles  in  the  atmosphere.  With 
that  exception  the  modes  of  communication  for  syphilis  might  be  the  same  as  those 
in  many  of  the  other  communicable  diseases.  It  is  conceivable  how  a  patient  might 
expectorate  matter  containing  spirochete  or  that  the  stools  or  urine  might  carry 
syphilis  virus.  In  isolating  a  syphilitic  patient  the  various  possibilities  of  infection 
should  be  borne  in  mind. 

Until  recently  it  had  been  very  definitely  understood  that  only  during  the  pri- 
mary and  secondary  manifestations  of  syphilis  was  the  disease  communicable  at 
all,  excepting  that  a  sufferer  from  the  tertiary  or  latent  stage  of  the  disease  could 
communicate  the  disease  to  offspring.  That  general  rule  seems  to  be  losing  ground, 
and  pathologists  are  coming  to  the  conclusion  that  some  of  the  tertiary  forms  of 
syphilis  may  also  be  communicable,  as,  for  instance,  the  gummata.  At  least, 
the  spiroehtetae  have  been  found  in  the  gummatous  tumors  of  syphilis,  and  they 
have  likewise  been  found  in  syphilitic  nodes  and  syphilitic  ulcers  in  different  parts 
of  the  body.  In  recent  years  a  diagnosis  of  the  disease  has  been  made  in  obscure 
cases  by  finding  the  micro-organism  of  syphilis  in  unsuspected  foci.  We  cannot 
any  longer  feel  the  same  amount  of  security  that  was  formerly  felt  in  dealing  with 
tertiary  syphilis  in  the  wards  of  a  general  hospital,  and  such  patients  should  be  iso- 
lated to  provide  a  double  security  to  patients  suffering  from  other  diseases. 

PYOCYANEUS 

The  pyocyaneus,  though  not  a  very  virulent  infection,  is  most  troublesome  in 
preventing  the  healing  of  the  wounds  of  postoperative  cases,  and  delays  the  recovery 
of  patients  oftentimes  to  a  most  exasperating  degree.  In  pyocyaneus-infected 
wards  slides  exposed  in  the  atmosphere  or  brought  in  contact  with  the  dust  of  walls 
or  floors  will  plate  out  almost  pure  cultures  in  the  first  generation.  Fortunately, 
this  is  one  of  the  easiest  of  the  infections  to  be  rid  of. 


PYOGENIC  INFECTIONS 

In  addition  to  the  above,  certain  surgical  infections  characterized  by  pus  forma- 
tion, usually  due  to  either  the  staphylococcus  or  streptococcus  micro-organisms, 
arc  not  of  infrequent  occurrence.  We  know,  of  course,  that  we  have  various  strains 
of  the  streptococcus  and  staphylococcus  everywhere  in  every-day  life  which  we  do 
not  regard  as  pathologic.  These  micro-organisms  are  harmful  only  under  certain 
conditions,  but  in  the  surgical  wards  of  a  hospital  and  especially  in  the  operating- 
rooms  they  are  harmful  at  all  times,  and  that  is  why  we  should  observe  strict 
asepsis  in  the  operating-rooms.  There  is  no  doubt  that  it  is  more  difficuH  to  infect 
a  pus-forming  wound  than  a  new  cut  made  in  the  operating-rooms,  because  in  this 
fresh  wound  an  immense  amount  of  absorption  takes  place  by  way  of  the  circulating 
blood  and  lymph.  In  a  pus  wound,  on  the  other  hand,  the  absorption  is  very  slight . 
if,  indeed,  there  be  any  at  all;  so  that  against  these  pus  infections  our  precautions 


436  OPERATION    OF   THE    HOSPITAL 

will  be  taken  almost  exclusively  in  the  surgical  operating-rooms,  and  they  must 
come  in  the  way  of  an  asepsis,  not  only  in  the  operation  itself,  but  in  the  preparation. 

In  all  these  infections,  after  a  patient  suffering  from  them  has  been  removed 
into  isolation,  it  will  be  highly  necessary  to  take  all  other  patients  out  of  the  room 
or  ward  and  to  fumigate  and  disinfect  the  room  and  its  contents  somewhat  after 
the  manner  which  we  shall  now  proceed  to  describe. 

DISINFECTION 

The  terms  "fumigation"  and  "disinfection"  seem  to  have  become,  by  common 
use,  interchangeable,  just  as  have  the  terms  "infectious"  and  "contagious."  As 
this  is  misleading  and  artificial,  there  is  a  disposition  to  discard  one  or  other  of 
these  terms.  It  may  be  well  to  use  the  term  "disinfection"  entirely,  notwithstand- 
ing the  fact  that  the  word  "fumigate"  implies  a  gaseous  process,  since  it  comes  from 
the  French  word  "fumier,"  meaning  smoke  or  vapor. 

Disinfection  is  the  process  by  which  articles  of  whatever  nature  are  freed  from 
micro-organisms.  There  are  many  agents  that  will  destroy  any  micro-organism 
under  proper  conditions;  so  that  the  question  before  us  is  to  determine  the  best 
agent  with  which  to  bring  about  the  destruction  of  harmful  micro-organisms  with 
the  greatest  possible  convenience  of  operation  and  at  the  lowest  expense  in  the 
situations  in  which  they  are  found  in  hospital  practice. 

Agents  of  disinfection  may  be  divided  into  two  classes:  physical  and  chemical. 

Physical  agents  may  be  subdivided  into  two  principal  classes:  dry  heat,  or  the 
process  of  burning;  and  wet  heat,  or  the  process  of  destroying  by  boiling  water  or 
steam. 

Chemical  agents  may  likewise  be  divided  into  two  classes :  those  in  the  form  of 
solutions  or  liquids  and  those  in  the  form  of  gases. 

Now  let  us  see  just  what  these  agents  mean  and  the  conditions  under  which 
they  may  be  best  used. 

The  burning  process  is  available  and,  in  fact,  best  of  all  for  those  infected  articles 
that  are  not  intended  to  be  kept,  such  as  books,  newspapers  and  magazines,  old 
rugs,  bandages  and  dressings  that  have  been  used  in  infectious  cases,  dirt  and  dust 
from  the  floors  and  walls,  and  the  sweepings  generally  from  infected  quarters. 

Boiling  water  will  destroy  any  micro-organism,  even  the  hardiest,  if  the  boiling 
process  is  continued  for  a  minimum  of  ten  minutes;  most  pathogenic  bacteria  are 
destroyed  in  five  minutes.  Linens,  dishes,  and  utensils  taken  from  infected  quar- 
ters should  be  boiled  for  at  least  ten  minutes.  This  process  is  efficient  and  is, 
perhaps,  cheaper  than  any  other  process  we  can  employ.  Blankets  and  other  woolen 
goods  will  not  stand  boiling.  Cutting  surgical  instruments,  such  as  scissors,  knives, 
and  needles,  should  not  be  boiled,  because  the  water  causes  oxidation  of  the  metal 
at  the  highly  tempered  cutting  edge  and  dulls  it;  they  should  be  soaked  in  carbolic 
acid. 

Both  live  steam,  or  steam  under  pressure,  and  latent  or  wet  steam  are  em- 
ployed for  disinfection  purposes.  Wet  steam  serves  our  purposes  not  very  much 
better  than  boiling  water,  since  the  temperature  does  not  very  much  exceed  the 
boiling-point.  Live  steam  is  much  more  effective.  Pressure  exerted  upon  steam 
causes  an  increase  of  temperature;  a  pressure  of  15  pounds  on  a  volume  of  steam 
will  raise  the  temperature  from  the  boiling-point,  212°  F.,  to  250°  F.  The  live- 
steam  apparatus,  used  for  sterilizing  dressings,  is  fitted  with  a  vacuum-producing 
appliance.     After  placing  the  articles — gloves,  linens,  dressings,  gauze,  etc. — in  the 


ISOLATION'    AND    DISINFECTION  437 

sterilizer,  a  vacuum  is  first  produced  to  draw  oul  all  possible  air;  after  ten  minutes 
the  live  steam  is  introduced,  twenty  minutes  sufficing  to  destroy  the  micro-organ- 
isms; the  vacuum  is  again  employed  to  remove  the  steam  from  the  sterilizer  and  its 
contents,  and  the  articles  may  then  lie  taken  from  the  sterilizer  dry  and  ready  for 

use.  This  dues  away  with  the  necessity  for  exposing  t he  articles  to  reinfection 
during  a  drying  process  in  the  open  air  after  removal  from  the  sterilizer. 

Naturally,  the  articles  that  we  sterilize  under  live  steam  in  these  dressing 
sterilizers  are  those  that  must  he  kept  sterile  after  thorough  disinfection  and  ready 
for  use  in  the  operating-room.  We  not  only  want  to  destroy  the  infectious  matter 
or  micro-organisms  that  may  be  present,  but  to  do  so  under  conditions  that  they 
may  he  kept  sterile  afterward,  as,  for  instance,  in  the  ordinary  laparotomy  drums. 

Chemical  Solutions. — Chemical  solutions  are  employed  for  disinfection  where  ii 
is  not  convenient  or  practicable  to  use  fire,  boiling  water,  or  steam.  There  are 
many  chemical  germicides,  and  new  ones  are  being  introduced  from  time  to  time, 
but  the  three  upon  which  we  have  come  to  rely  for  institutional  work  are:  carbolic 
acid,  bichlorid  of  mercury,  and  the  various  chlorin  solutions. 

Chlorin. — The  chlorins  are  destructive  basically;  they  are  bleachers,  and  they 
destroy  fabrics.  In  addition,  the  chlorin  compounds  are  much  more  expensive  than 
others,  so  that  for  disinfection  purposes  solutions  are  reduced  to  a  choice  between 
carbolic  acid  and  bichlorid  of  mercury.  It  may  be  doubted  whether  chlorid  of 
lime  sprinkled  into  toilet  bowls  and  in  catch  basins  is  much  more  than  a  deodorizer. 
and  it  is  very  certain  that  its  effectiveness  is  limited  to  the  micro-organisms  with 
which  it  comes  into  actual  contact. 

Carbolic  Acid. — In  the  use  of  carbolic  acid  we  have  a  choice  of  two  strengths — 
either  the  so-called  chemically  pure,  or  95  per  cent,  solution,  and  the  concentrated 
aqueous  solution,  which  will  not  exceed  5  per  cent.,  because  carbolic  acid  is  very 
slightly  soluble  in  water.  Either  of  these  strengths  will  destroy  any  of  the  micro- 
organisms, the  difference  being  one  of  time  alone.  A  95  per  cent,  solution  of  car- 
bolic acid  will  destroy  spore-bearing  micro-organisms,  such  as  anthrax,  in  two  or 
three  minutes,  whereas  the  2\  or  5  per  cent,  solution  may  require  several  hours  to 
perform  the  same  work.  We  use  the  95  per  cent,  carbolic  acid,  however,  for  very 
few  purposes  because  of  its  destructiveness  and  the  likelihood  of  its  burning  those 
who  are  working  with  it.  The  principal  use  of  the  strong  carbolic  acid  is  for  the 
immediate  sterilization  of  cutting  instruments  in  the  operating-room.  As  men- 
tioned previously  in  the  section  under  Operating-room  Technic,  it  is  the  common 
method  to  immerse  instruments,  especially  the  cutting  instruments,  in  a  95  percent, 
solution  of  carbolic  acid  for  three  or  four  minutes,  then  to  rinse  them  in  alcohol, 
and  finally  in  sterile  water.  This  procedure  does  not  destroy  the  cutting  edge  and 
allows  the  continuous  use  of  one  of  these  instruments  throughout  an  operation  by 
providing  a  ready  means  of  resterilizing  if  it  has  touched  pus  or  some  infected  area 
in  the  operating  field.  The  1\  or  5  per  cent,  carbolic  acid  solution  has  a  vast  field 
of  usefulness.  It  is  often  impracticable  to  destroy  infectious  excreta  like  feces  and 
urine  by  boiling  them,  and  this  may  be  done  fairly  satisfactorily  in  a  weak  solution 
of  carbolic  acid  if  the  process  is  continued  for  a  sufficient  length  of  time:  wherever 

possible  it  is  desirable  to  leave  infected  material  in  carbolic  acid  over  night  or  for 
aboul  that  long  a  period,  and  to  add  some  chemical  like  hydrochloric  acid  to  break 
down  any  albuminous  envelope  in  which  the  micro-organisms  have  become  encased. 
Linens,  excreta,  dishes,  or  cutlery  that  have  been  used  by  infected  patients  can  tie 
efficiently  sterilized  in  these  2\  or  5  per  cent,  carbolic  solutions. 

There  are  two  objections  to  the  use  of  carl  ml  ic  acid:  one  is  the  disagreeable  i  idol', 

especially  in  institution  practice,  where  the  odor  of  carbolic  acid  is  recognized  a- 


438  OPERATION    OF    THE    HOSPITAL 

the  odious  "hospital  smell";  the  other  objection  is  its  irritating  effect  on  the  hands 
of  those  who  work  with  it  in  even  the  low  percentages.  There  are  persons  whose 
hands  will  not  permit  the  use  of  even  a  1  per  cent,  carbolic  acid  solution,  while  a 
2\  or  5  per  cent,  solution  is  irritating  to  the  most  tolerant  skin. 

Bichlorid  of  Mercury. — The  objection  to  corrosive  sublimate  solution,  even  in 
the  high  percentages,  is  that  in  coming  in  contact  with  infectious  matter  like  pus, 
or  infected  blood  or  excreta  of  any  kind,  it  unites  with  the  albuminous  matter  in 
these  materials  to  form  an  albuminate  of  mercury,  which  forms  a  coat  or  shell  over 
the  matter  to  be  disinfected,  and  acts  as  a  protection  to  the  micro-organism  by  pre- 
venting the  penetration  of  the  disinfecting  solution.  This  objection,  however,  is 
readily  overcome  by  adding  to  the  corrosive  sublimate  solution  a  small  amount  of 
a  5  per  cent,  solution  of  tartaric  or  citric  acid,  sodium  chlorid,  or  ammonium. 

Naturally,  bichlorid  solutions  cannot  be  used  to  disinfect  metals,  because  they 
form  a  coat  of  mercury.  However,  corrosive  sublimate  solutions  do  not  destroy 
fabrics  of  any  kind,  and  they  are  not  hurtful  to  the  hands  or  exposed  skin  of  those 
who  use  them,  excepting,  of  course,  in  a  very  concentrated  strength,  and  it  is  not 
necessary  to  use  such  solutions  as  this.  Even  solutions  of  1  :  500  will  hardly  hurt 
the  hands. 

Like  nearly  all  of  the  other  disinfecting  agents,  the  question  of  concentration 
of  corrosive  sublimate  is  a  question  of  time  rather  than  efficiency;  1  :  500  solution 
will  destroy  almost  any  of  the  micro-organisms  in  a  few  minutes,  but  1  :  10,000  will 
destroy  almost  any  of  them  in  twelve  hours ;  if  we  are  to  disinfect  because  of  any 
of  the  ordinary  infectious  diseases,  we  may  perhaps  strike  a  happy  medium  of  1  :  2000 
for  articles  that  must  be  cleansed  in  a  few  minutes,  using  the  greater  dilution  for 
those  things  that  can  be  left  to  stand  over  night  in  the  disinfecting  solution. 

The  bichlorid  solutions  have  no  odor  and  will  often  be  preferred  on  that  ac- 
count to  carbolic  acid.  Bichlorid  of  mercury  is  cheap,  and  its  use  need  not  entail 
any  considerable  expenditure  under  any  circumstances.  Great  care  must,  of  course, 
be  taken  to  keep  it  beyond  the  reach  of  animals  or  children,  because  it  is  extremely 
poisonous  when  taken  internally. 

Gases. — There  are  a  number  of  irritant  gases  which,  when  used  properly  and 
under  favorable  conditions,  will  destroy  most  of  the  micro-organisms  that  can  by 
any  chance  be  considered  harmful  to  the  human  body.  There  are  disadvantages 
connected  with  the  use  of  most  of  these  gases,  and,  therefore,  manufacturing 
chemists  have  from  time  to  time  placed  upon  the  market  new  gaseous  agents  to 
be  operated  under  new  processes,  some  of  them  simple  and  some  complicated,  but 
all  of  them  advertised  with  an  attractiveness  that  rather  favors  their  use.  Only 
three  gases,  however,  are  really  worthy  of  consideration,  and  one  of  these,  chlorin, 
may  be  discarded  because  of  its  destructiveness  to  fabrics  of  all  kinds  and  its  hurt- 
ful bleaching  properties.     The  other  two  are  sulphur  and  formaldehyd. 

Sulphur. — When  used  as  a  fumigating  gas,  the  procedure  is  as  follows:  Take 
5  pounds  of  rock  or  rolled  sulphur  for  each  1000  cubic  feet  of  air  space,  divide  it 
into  small  particles  about  the  size  of  a  filbert,  add  a  sufficient  quantity  of  alcohol 
to  permeate  the  sulphur,  set  the  whole  in  a  metal  pot  several  inches  above  the 
floor,  and  surround  the  container  by  water  to  avoid  all  chances  of  fire. 

If  the  area  to  be  fumigated  is  made  air-tight  by  sealing  the  cracks  around  the 
windows  and  doors  this  disinfecting  gas  will  destroy  every  micro-organism  with 
which  it  comes  in  contact.  Because  of  its  special  power  to  destroy  vermin,  insects, 
rats  and  mice,  mosquitos,  bed-bugs,  and  cockroaches,  this  gas  is  employed  more 
frequently  on  shipboard  and  under  the  quarantine  regulations  of  all  civilized  nations 
than  any  other  gaseous  disinfectant.    The  area  to  be  fumigated  should  be  left  sealed 


ISOLATION    AND    DISINFECTION  130 

for  not  less  than  twenty-four  hours,  and  should  (hereafter  be  aired  for  at  least 
twenty-four  hours  more,  with  all  windows  and  doors  open,  before  permitting  a 
person  to  use  it  for  habitation.  The  penetrating  power  of  sulphur  disinfection 
depends  almost  wholly  upon  the  amount  of  moisture  in  the  atmosphere  during  the 
disinfecting  process.  The  atmosphere  may  lie  moistened  by  hanging  up  sheets  which 
have  been  wet  or  by  vaporizing  water  by  heat.  Laboratory  experts  tell  us  that 
about  1  pint  of  water  should  be  evaporated  for  each  1000  cubic  feet  of  space  to  lie 
disinfected.  It  may  be  added  that  this  moisture  is  sometimes  produced  by  allow- 
ing the  radiator  vent  to  remain  slightly  open,  allowing  a  quantity  of  steam  to  es- 
cape into  the  room.  Sulphur  is,  like  chlorin,  a  great  bleaching  agent,  and  should 
not  be  used  where  there  are  colored  fabrics. 

Formaldehyd. — Nearly  all  the  manufacturing  chemists  have  on  the  market  some 
proprietary  form  of  formaldehyd  disinfectant.  Usually  these  purchasable  disin- 
fectants come  in  the  form  of  a  candle  or  lamp  arrangement.  Most  of  them  are 
inefficient.  Some  of  them  are  strong  and  perform  the  work  of  liberation  of  the 
gas  in  a  few  minutes.  In  others  the  dilution  is  higher  and  the  time  of  liberation 
extended. 

In  large  institutions,  and  where  the  saving  of  material  is  an  item,  formaldehyd 
disinfection  maybe  reduced  to  perhaps  its  very  lowest  cost  and  its  highest  efficiency 
in  the  following  manner: 

Formalin,  or  40  per  cent,  formaldehyd  solution,  may  be  purchased  at  11  cents 
per  pound  in  kegs  of  135  pounds.  Unless  great  quantities  are  to  be  used  it  will 
not  be  expedient  to  buy  more  than  135  pounds  at  one  time  because  of  a  certain 
amount  of  deterioration.  Permanganate  of  potash  may  be  purchased  in  small 
crystals  at  11|  cents  per  pound  in  kegs  of  112  pounds.  Any  kind  of  metal  pot  with 
a  large  mouth  may  be  employed  in  the  fumigating  process,  as  long  as  it  is  suffi- 
ciently large  to  provide  for  the  escape  of  vapor.  A  4-gallon  kettle  is  most  suit- 
able. For  each  1000  cubic  feet  of  space  to  be  disinfected  the  proportions  will  be 
1  pint,  or  1  pound  of  the  formalin  to  8  ounces  of  permanganate,  and  this  means  an 
expenditure  of  17  cents  for  each  1000  cubic  feet  of  space  to  be  disinfected. 

Before  the  two  materials  are  poured  together  the  pot  should  be  set  upon  bricks 
or,  at  least,  upon  some  non-combustible  base  several  inches  above  the  floor,  and 
all  windows,  ventilators,  and  doors  should  be  sealed  excepting  the  one  door  to 
provide  an  exit  for  the  person  who  starts  the  process,  and  paste,  paper,  and  brush 
must  be  ready  for  this  door  before  the  process  is  started,  so  that  the  sealing  can  be 
completed  immediately  after  the  last  person  leaves  the  room. 

Just  as  in  the  case  of  sulphur  disinfection,  the  efficiency  of  formaldehyd  gas  will 
depend  to  a  great  extent  upon  the  amount  of  moisture  in  the  room,  but  it  will  also 
depend  greatly  upon  the  temperature  of  the  room.  For  formaldehyd  disinfection 
the  radiators  should  be  turned  on  or  some  form  of  artificial  heat  employed,  as,  for 
instance,  a  salamander  or  stove  to  raise  the  temperature  of  the  room  to  80°  F.  or 
more.  Then,  if  in  addition  to  this  high  temperature  the  walls  are  sprinkled  with 
water  as  available  moisture,  the  penetrability  of  formaldehyd  gas  will  reach  its 
maximum.  The  germicidal  power  of  formaldehyd  upon  micro-organisms  of  all 
sorts,  under  such  conditions,  is  considerable;  but,  unfortunately,  formaldehyd  gas 
does  not  destroy  vermin,  such  as  cockroaches,  bed-bugs,  <ir  even  mice  and  rats, 
unless  concentrated  to  a  degree  and  maintained  for  a  length  of  time  out  of  all 
reason  for  purposes  of  institution  fumigation. 

Institution  executives  have  been  living  in  the  hope  that  some  certain  means 
of  efficient  fumigation  might  be  found  for  treating  rooms  and  wards  that  have 
recently  housed  communicable  infections.     It  seems  that  their  hopes  are  Q01  ye1 


440  OPERATION   OF   THE    HOSPITAL 

realized.  Anderson,  of  the  Public  Health  and  Marine  Hospital  laboratories  at 
Washington,  and  a  number  of  other  excellent  pathologists  have  recently  done  much 
valuable  work  in  this  field,  but  the  net  results  to  date  seem  to  consist  of  a  warning, 
in  chorus,  that  no  fumigant  yet  suggested  is  efficient  for  the  destruction  of  the 
pathogenic  micro-organisms  at  large  in  the  ordinary  hospital  room  or  ward  under 
the  conditions  that  prevail  during  its  employment.  Negative  results  are  said  to 
be  many  times  quite  as  valuable  as  those  that  are  positive,  and  this  is  almost  true 
in  this  case;  at  least,  if  we  have  proper  warning  that  the  elaborate  technic  of  fumiga- 
tion that  most  of  us  are  accustomed  to  employ  is  futile,  we  are  enabled  to  protect 
our  patients  by  not  subjecting  them  to  the  hazards  of  infection  under  conditions 
most  likely  to  be  disastrous.  For  instance,  we  would  not  be  likely  to  place  a  mater- 
nity patient  in  a  room  that  had  recently  housed  puerperal  fever,  or  a  surgical  case 
in  quarters  where  erysipelas  had  been  recently. 

In  the  Michael  Reese  Hospital  the  process  of  fumigation  has  consisted  of  the 
formaldehyd-permanganate  system  above  described,  followed  by  a  thorough  wash- 
ing of  the  walls  and  ceiling  of  the  room  with  a  5  per  cent,  carbolic  acid  solution, 
and  a  thorough  washing  of  the  floor  with  the  same,  with  a  subsequent  scrubbing 
with  hot  water  and  soap.  All  the  furniture  and  fixtures  are  washed  with  carbolic. 
Mattresses,  blankets,  rugs,  and  curtain  material  are  placed  in  the  mattress  steril- 
izer under  300°  F.  of  alternate  vacuum  and  dry  heat  for  one  hour.  We  feel  that 
even  after  this  treatment  we  are  not  justified  in  placing  in  the  quarters  any  patient 
who  would  be  susceptible  to  such  an  infection. 

PLANS  FOR  ISOLATION  UNIT 

In  connection  with  the  section  on  Isolation  and  Disinfection,  it  would  seem 
to  be  appropriate  to  produce  the  major  plans  for  a  small  isolation  hospital  to  be 
operated  in  connection  with  the  Michael  Reese  Hospital,  of  Chicago. 

This  building  is  intended  to  care  for  communicable  infections  that  develop  in 
the  main  hospital. 

There  are  a  few  very  important  factors  to  be  considered  in  providing  a  perma- 
nent isolation  unit: 

1.  The  construction  must  be  such  that  the  quarters  can  be  fumigated  and  dis- 
infected most  thoroughly  without  damage  to  the  walls,  floors,  ceilings,  doors, 
windows,  and  window  frames. 

2.  Arrangements  must  be  included  in  the  architecture  by  which  food  may  be 
passed  to  the  occupants  of  the  unit  without  clanger  of  passing  the  infection  to  the 
orderly  carrying  it. 

3.  Arrangements  must  be  made  in  the  architecture  by  which  soiled  linens,  used 
dishes,  and  garbage  may  be  passed  out  of  the  unit  without  danger  of  infection  to 
those  receiving  them. 

4.  Architectural  arrangements  must  be  included  by  which  a  patient  and  nurse 
may  be  cleaned  up  and  cleared  out  of  the  premises  without  taking  any  of  the 
elements  of  infection  with  them. 

5.  The  architecture  must  provide  quarters  for  the  visiting  physician  where  he 
may  rest  in  cases  of  emergency,  and  where  he  may  be  permitted  to  change  cloth- 
ing for  each  class  of  infections,  and  enter  and  re-enter  his  quarters  without  cross- 
ing an  infected  area  while  wearing  clean  apparel.  In  other  words,  it  must  be  so 
arranged  that  he  can  step  into  his  quarters,  dispose  of  his  outer  garments  and  shoes, 
clothe  himself  in  proper  protective  apparel,  leave  his  quarters,  visit  a  patient  in 
the  building,  return  to  the  quarters,  put  aside  his  infected  clothing,  put  on  other 


ISOLATION    AND   DISINFECTION 


441 


clean  clothing,  visit  another  patient  suffering  from  a  different  infection,  and  repeat 
these  visits  as  many  times  as  there  arc  classes  of  infection  in  the  huilding. 

If  we  have  covered  all  of  these  points  in  the  architecture  of  an  isolation  unit, 
we  have  met  all  the  practical  necessities  of  the  occasion. 

Now  let  us  describe  the  plans  for  this  isolation  building  somewhat  in  detail: 

The  first  drawing,  Fig.  157,  shows  a  basement  floor  that  may  go  as  far  beneath 
the  surface  as  necessary,  and  rise  high  enough  for  a  10  or  11  foot  ceiling.  This 
whole  building  is  G2  feet  long  over  all,  and  26  feet  8  inches  wide,  not  including 
porches,  areaways,  or  projecting  stairs,  and  has  an  11  foot  basement,  a  first  floor 
with  11  foot  ceilings,  and  a  second  floor  with  a  10  foot  ceiling. 

Let  us  take  first  the  physician's  suite  of  the  basement  plan.  The  door  enters 
the  areaway  into  a  lounging  room  in  which  there  is  supposed  to  be  couch,  tallies, 
chairs,  and  reading  matter,  and  a  series  of  lockers  in  which  to  hang  his  outer  gar- 
ments. When  he  desires  to  prepare  for  a  visit  to  a  patient  upstairs  he  walks  into 
the  room  marked  "Hall,"  and  across  into  the  dressing-room,  where  he  may  leave 


Fig.  157. — Isolation  department — administration  suite. 


his  shoes,  trousers,  coat,  vest,  and  shirt,  then  back  again  into  the  hall  to  take  visit- 
ing garments  from  the  lockers  in  the  hallway.  He  then  retraces  his  steps  into  the 
lounging  room  and  out  into  the  areaway,  up  the  stairs,  and  proceeds  up  any  flight 
of  stairs  that  may  lead  him  to  the  suite  he  wishes  to  visit.  When  the  visit  is  at 
an  end  he  returns  to  the  surface  of  the  ground  and  into  the  areaway  on  the 
other  side  of  the  building,  along  that  areaway  until  he  comes  to  the  door  of  the 
room  marked  "Disrobing  Septic  Room."  There  he  removes  the  head-cloth,  mouth- 
cloth,  gloves,  visiting  coat,  and  white  trousers.  He  then  walks  to  the  door  leading 
back  into  the  hall  from  which  he  originally  went,  and  at  the  doorway  leaves  his 
white  canvas  shoes,  or  throws  them  back  into  the  septic  room  as  he  leaves  it.  He 
may  then  take  other  visiting  apparel  from  another  locker,  and  visit  another  patient, 
and  repeat  those  visits  as  many  times  as  necessary,  always  taking  the  same  route. 
When  his  final  visit  is  made  and  he  wishes  to  clean  up,  he  walks  along  the  hallway 
until  he  comes  to  the  bath-room,  removes  all  of  his  clothing,  takes  a  shower-bath, 
steps  through  the  partition  door  into  the  dressing-room,  where  he  dons  his  street 
clothing,  and  goes  thence  over  to  the  lounging  room,  and  from  there  out  into  the 


442  OPERATION   OF   THE    HOSPITAL 

street.  It  will  be  seen  that  in  making  this  journey  and  repeating  it  any  number  of 
times  he  does  not  cross  his  path  at  any  time.  He  does  not  have  septic  clothing 
on  him  except  in  the  septic  disrobing  room,  all  the  other  parts  of  his  suite  being 
clean. 

The  room  marked  "Sterilizing  Room"  is  that  in  which  all  the  isolation  department 
clothing  is  sterilized  by  a  nurse  charged  with  that  duty,  and  after  the  sterilizing 
process  is  ended  she  refurnishes  the  lockers  in  the  hallway  with  sufficient  apparel  to 
meet  the  demands  of  the  next  day  or  any  subsequent  time. 

If  this  technic  is  carefully  followed,  it  would  seem  that  the  chances  of  carrying 
infection  by  the  physician  are  reduced  to  an  absolute  minimum. 

The  middle  of  the  basement  floor  is  occupied  by  a  long  room  12  feet  wide,  run- 
ning the  width  of  the  building.  There  is  a  vestibule  at  either  end  of  this  small 
suite,  and  a  partition  running  the  length  of  the  room  between  the  vestibules,  divid- 
ing this  12  foot  space  into  two  long  suites,  26  feet  8  inches  long  and  6  feet  wide  each. 
This  suite  is  to  be  used  as  clearing  space  for  nurse  and  patient.  If  the  patient  is 
an  adult,  or  old  enough  to  bathe  and  put  on  street  clothing,  he  walks  out  of  the 
apartment  when  he  is  finally  released  by  the  physician,  goes  down  the  areaway  at 
the  upper  right-hand  corner  of  the  plan  as  we  see  it,  and  into  the  second  door  that 
he  meets.  He  opens  the  door  to  his  left,  walks  into  the  room,  takes  off  his  infected 
clothing,  which  is  made  up  of  wash  goods,  and  drops  it  into  a  septic  tank  provided 
for  the  purpose  in  the  corner  of  the  room,  and  made  up  of  a  3  or  5  per  cent,  carbolic 
acid  solution.  He  then  walks  into  the  next  room  without  clothing,  takes  a  bichlorid 
bath,  including  the  hair,  in  the  tub,  dries  himself,  and  puts  on  the  street  clothing 
previously  placed  there  for  the  purpose.  He  then  leaves  the  premises  no  longer  a 
menace  to  the  community. 

After  the  nurse  has  completed  her  work  of  straightening  up  the  apartment 
and  preparing  it  for  subsequent  fumigation  and  disinfection,  she  follows  the  course 
of  the  patient,  excepting  that  she  takes  the  other  side  of  the  suite,  and  goes  through 
the  same  cleaning-up  process,  emerging  from  the  same  clean  exit,  and  is  out  in  the 
world  again.  An  electric  fan  may  be  provided  in  the  clean  apartment,  so  that  she 
may  dry  her  hair  rapidly. 

The  situation  is  somewhat  complicated  if  the  patient  is  a  child  unable  to  per- 
form the  office  of  disrobing,  bathing,  and  reclothing  itself,  and  in  that  event  the  nurse 
will  take  the  child  into  the  patient's  side  of  the  clearing  house,  and  after  she  has 
disrobed  the  child  and  set  it  into  the  clean  room,  she  will  have  to  step  back  into  the 
septic  room  again,  take  off  at  least  her  outer  garments,  put  on  sterile  gown,  gloves, 
and  head-cloth.  Then  she  will  have  to  take  the  child  through  the  bath  into  the 
clean  clothes  room,  and  finally  pass  the  child  to  a  clean  nurse  on  the  outside.  She 
will  have  previously  set  her  rooms  upstairs  in  order,  so  that  it  will  be  only  uecessary 
for  her  to  retrace  her  steps  through  the  way  she  has  come,  over  into  her  own  side 
of  the  clean  quarters,  and  make  her  way  to  the  outside  world,  as  previously  de- 
scribed. 

If  this  technic  shall  have  been  carried  out  faithfully,  it  seems  there  is  hardly 
even  a  remote  chance  of  conveying  an  infection  from  the  apartments  by  either 
nurse  or  patient. 

The  remaining  part  of  the  basement  floor  is  left  for  storage  room.  It  had 
been  originally  intended  that  this  remaining  room  should  be  finished  as  an  operat- 
ing-room in  the  event  that  a  patient  in  isolation  required  surgical  interference. 
The  element  of  cross-infections  in  such  cases  seemed  too  hazardous  to  permit  of 
this  plan,  and  it  is  designed  that  a  necessary  surgical  operation  shall  be  performed 
in  the  suite  in  which  the  patient  is  located. 


ISOLATION'    AND    DISIXKKCTIOX 


443 


Now  let  us  go  to  Fig.  158,  which  contains  two  complete  units  of  isolation,  each 
one  for  a  different  infection.  There  is  in  one  of  these  suites  a  ward  15  feet  square, 
with  a  window  at  the  stairway  at  the  side  of  the  plan,  and  a  second  window  at 
the  foot  of  the  plan,  opening  out  onto  the  porch.  This  window  goes  to  the  floor, 
as  it  is  intended  that  a  patient  on  a  stretcher  may  be  carried  into  the  ward  through 
the  window  rather  than  through  the  door  into  the  small  kitchen,  and  thence  into 
the  ward. 

The  dotted  lines  across  this  ward  form  a  triangle,  representing  brass  or  nickeled 
tubing  running  on  anchors  from  the  ceiling.  It  may  be  that  sometimes  there  will 
be  a  male  and  two  female  patients  suffering  from  the  same  infection,  and  curtains 
may  be  hung  as  screens  from  these  hangers. 

Now  let  us  take  the  small  kitchen  at  the  foot  of  the  plan — let  us  say,  the  suite 
at  the  left  hand.     There  are  in  this  room  gas  plate,  sink,  and  small  table. 


Fig.  15S. — Two  isolation  units. 


The  next  room,  marked  "Sterilizing  and  Clean  Room,"  contains  a  utensil  steril- 
izer and  a  small  instrument  or  dressing  boiler. 

At  the  top  of  the  plan  is  a  private  room  with  bath  for  a  private  patient,  and  a 
private  room  with  bath  for  the  nurse.  A  small  passageway  from  this  apartment 
leads  out  into  a  hallway  at  the  center  of  the  building,  the  purposes  of  which  hallway 
will  be  described  later.  This  isolation  suite  is  duplicated  on  the  first  floor  and  on 
the  second  floor,  forming  four  units  of  isolation,  each  one  of  them  entered  from  an 
entirely  separate  entrance,  and  each  of  these  units  has  a  small  balcony  in  front, 
which,  in  our  own  particular  case,  faces  Lake  Michigan,  and  is  intended  to  furnish 
a  comfortable  lounging  place  for  convalescent  patients,  who  are  separated  by  10 
feet  of  areaway  between  the  porches,  and  also  by  a  6  foot  solid  wall  between  them. 

Now  let  us  take  up  the  center  hallway  running  across  the  entire  building. 
This  hallway  is  10  feet  wide,  runs  to  the  top  of  the  second  story,  and  is  open  at 
both  ends.  A  small  stair  runs  from  the  first  to  the  second  floor,  as  shown  in  the 
plan.     The  purpose  of  this  open  hallway  is  to  serve  as  a  medium  of  connnunieation 


444 


OPERATION    OF   THE    HOSPITAL 


for  the  compartments  with  the  outside  world.  Food  is  brought  by  the  orderly 
for  the  compartment,  and  passed  through  the  window  into  the  kitchen  or,  rather, 
set  upon  the  slate  shelf  of  the  window,  so  that  the  nurse  can  reach  it.  In  our  own 
case  a  covered  metal  tray  with  hot-water  compartments  below  and  tight  metal  cover 
is  used  for  conveying  all  food  from  the  hospital  kitchen  to  the  infectious  building. 
This  tray  is  described  under  the  section  on  Equipment. 

Now  let  us  see  how  we  are  to  dispose  of  the  soiled  linens,  garbage,  and  soiled 
dishes.  Under  the  window  in  the  sterilizing  room  is  an  enclosed  space  with  two 
small  doors,  flush  with  the  wall  on  the  hallway,  and  projecting  into  the  room  6  or 
8  inches  on  the  inside,  with  a  sloping  lid.  This  makes  a  small  tight  compartment 
about  30  inches  high,  18  inches  deep,  that  is,  from  hall  to  sterilizing  room,  and  the 
width  of  the  window.  A  galvanized  iron  or  porcelain  lined  tank  is  made  to  exactly 
fit  this,  with  sloping  edge  inwardly  to  conform  to  the  sloping  lid.     There  is  a  hose 


Fig.  159. — Wall  receptacle  between  room  and  corridor  for  dishes  or  linens. 


faucet  in  this  large  hallway,  with  hose,  to  permit  the  filling  of  the  tanks,  and  a  low 
zinc-lined  sewer  inlet  for  emptying  the  tanks.  It  is  the  clean  orderly's  business  to 
see  that  this  tank  is  filled  with  a  2|  or  5  per  cent,  carbolic  solution  each  day.  When 
the  nurse  desires  to  dispose  of  soiled  linens,  she  merely  lifts  her  sloping  lid  to  the 
tank,  drops  the  linen  in,  and  closes  the  lid.  She  will  not  have  touched  the  tank 
at  any  point,  and  the  orderly  can  come  twelve  hours  later,  wring  out  and  remove  the 
soiled  linens,  which  have  been  thoroughly  sterilized  by  this  process,  take  them  to 
the  laundry  of  the  hospital,  where  they  can  be  rinsed  in  clean  water  to  dispose  of 
the  carbolic  odor. 

In  each  small  kitchen  under  the  window  are  two  tanks  half  the  size  of  that 
just  described  for  the  linens,  one  of  these  to  contain  the  garbage,  the  other  the 
soiled  dishes  and  the  tray. 

If  the  technic  is  properly  carried  out  in  the  matter  of  these  several  tanks  and 
their  usage,  it  is  believed  that  the  sources  of  infection  between  the  inside  and  out- 


ISOLATION    AND   DISINFECTION  445 

side  of  the  infected  quarters  will  be  reduced  to  as  low  a  point  as  is  possible  under 
working  conditions.     Fig.  159  shows  a  view  of  the  mandrel]  and  tank. 

In  our  own  particular  case  the  architecture  of  this  building  is  12-inch  block  tiles 
for  the  walls,  stuccoed  on  the  outside,  plastered  on  the  inside  with  Keene  cement, 
which  has  the  capacity  to  resist  steam,  and  painted  with  imported  zinc  enamel, 
which  also  has  the  capacity  to  resist  steam. 

The  fumigation  and  disinfection  of  this  unit  after  it  is  vacated  is  as  follows: 

Each  unit  is  provided  with  pressure  steam  outlet  to  be  used  with  steam  hose 
sufficiently  long  to  reach  the  remotest  room  of  the  suite.  Each  suite  is  also  fitted 
with  cold-water  outlet  to  be  used  with  hose  connection. 

The  first  step  in  the  disinfection  will  be  formaldehyd  permanganate,  as  pre- 
scribed elsewhere  in  this  section. 

Second,  releasing  of  live  steam,  with  the  operator  holding  the  nozzle  by  a  6-foot 
handle,  the  steam  being  applied  to  every  part  of  each  room. 

The  third  step  is  a  thorough  washing  of  the  walls,  floors,  ceiling,  and  furniture 
with  a  5  per  cent,  carbolic  solution,  and  the  final  step  a  thorough  rinsing  of  every- 
thing in  the  unit  with  cold  water. 


THE   X-RAY  DEPARTMENT 

The  x-ray  has  made  vast  strides  within  the  past  few  years;  has  been,  in  fact, 
revolutionized.  Not  long  ago  good  pictures  of  the  long  bones  were  the  x-ray 
limit.  Later  on,  stone  in  the  bladder  and  kidney  was  established  as  the  acme  of 
x-ray  perfection.  Five  years  ago  it  was  almost  an  unheard  of  thing  to  show  on  an 
x-ray  plate  a  pus-sac  in  the  antrum,  pus  in  the  frontal  sinus,  and  a  good  sella 
turcica.  An  outline  of  the  stomach  by  the  use  of  bismuth  emulsion  was  considered 
the  last  word  of  x-ray  practice.  We  had  not  then  begun  to  outline  the  colon  in  all 
its  length  by  the  use  of  bismuth  emulsions.  We  are  doing  so  as  routine  practice 
to-day.  We  had  not  yet  thought  of  outlining  tuberculous  areas  in  the  lung;  we 
are  doing  so  to-day  without  comment.  The  mediastinal  glands  had  not  been  dis- 
covered in  the  x-ray;  any  passable  picture  now  contains  them,  and  we  are  to-day 
outlining  calcined  tuberculous  deposits  in  the  mesentery  and  abdominal  cavity 
generally.  It  is  no  uncommon  practice  to  show  malignant  tumors  about  the  stom- 
ach and  intestines.  Most  of  the  organs  of  the  abdominal  cavity  are  outlined  by 
the  best  operators — the  stomach,  liver,  kidneys  and  spleen,  and  the  bladder — 
by  the  use  of  solutions.  Abnormalities  of  the  kidney,  pelvis,  and  ureters  are  easily 
demonstrable  by  the  use  of  collargol,  as  abnormalities  in  size,  shape,  and  lumen 
of  the  ureters  are  easily  discerned  by  the  use  of  the  ureteral  radiographic  sound 
and  catheter. 

We  are  going  along  toward  a  time  when  the  demonstration  of  anatomic  abnor- 
malities is  only  a  question  of  mechanical  technic  in  the  manufacture  of  the  appa- 
ratus and  the  skill  of  the  operator. 

There  are  two  directions  of  improvement  immediately  confronting  the  x-ray 
operator  of  the  day,  and  in  order  to  achieve  this  improvement  he  must  work  in 
consonance  with  the  clinician  and  with  the  mechanic  devoted  to  the  improvement 
of  the  x-ray  apparatus.  These  two  directions  are:  First,  rapidity  of  x-ray  execu- 
tion to  the  point  that  will  show  physiologic  movements  of  the  heart,  lungs,  and 
intestines,  that  is,  diastole  and  systole  of  the  heart;  the  degree  of  expansion  of  the 
lung,  and  peristaltic  movements  of  stomach,  small  intestine,  and  colon.  Second, 
the  use  of  the  x-ray  in  the  treatment  of  disease,  that  is,  in  the  dissipation  of  tumors 
that,  because  of  their  nature  or  location,  are  inoperable;  the  treatment  of  skin 
lesions,  such  as  lupus,  favus,  and  ringworms,  and  the  destruction  of  highly  vascular 
areas,  such  as  nevus,  postoperative  keloids,  and  hemorrhoids,  and  the  dissipa- 
tion of  inflammatory  products  in  certain  of  the  glands,  especially  in  goiter. 

It  will  not  be  profitable  for  us  to  do  more  than  merely  mention  the  above 
directions  in  which  the  modern  x-ray  is  moving  in  institution  work,  because  a 
further  discussion  along  this  line  would  lead  us  clearly  within  the  realm  of  scientific 
medicine. 

Before  we  go  into  the  question  of  x-ray  equipment,  let  us  say  a  few  words  about 
the  modern  x-ray  operator.  No  operator  can  be  a  success  who  does  not  know 
sufficient  about  his  apparatus  to  take  it  apart  and  put  it  together  again.  He 
must  know  the  underlying  principles  operating  in  all  the  parts  of  his  machine,  the 
purposes  for  which  each  part  is  used,  and  the  reasons  why.  He  must  have  a 
reasonably  sure  knowledge  of  the  laws  of  light,  so  that  he  will  know  the  x-ray, 

446 


THE   X-RAY    DEPARTMENT  447 

physically  to  distinguish  it  from  other  ether  waves.  He  should  be  a  good  chemist, 
because  the  most  intricate  principles  of  chemistry  are  involved  in  roentgenography. 
He  must  be  a  mechanic  of  no  mean  order,  because  nine-tenths  of  the  x-ray  equip- 
ment involves  mechanical  principles;  and  he  must  be  an  electophysicist,  because 
some  of  the  principles  involved  in  the  x-ray  equipment  delve  very  deeply  into  the 
realm  of  scientific  electricity.  He  should  be  a  photographer,  first,  because  the  value 
of  the  x-ray  plate  when  finished  depends  in  a  very  large  measure  upon  its  develop- 
ment in  the  dark  room;  second,  because  nearly  every  institution  nowadays  does 
more  or  less  photography,  and  unless  the  x-ray  operator  is  a  very  busy  person, 
there  will  hardly  be  any  one  quite  so  adaptable  for  purposes  of  photography  as  the 
x-ray  operator. 

It  goes  without  saying  that  the  x-ray  operator  should  be  a  person  of  liberal 
medical  education,  a  good  anatomist,  a  good  general  pathologist,  and  a  good 
physiologist,  to  the  end  that  he  may  be  able  to  aid  the  clinician  in  the  interpreta- 
tion of  his  plates. 

It  goes  without  saying  that  so  many-sided  a  person,  one  sufficiently  versed  in 
so  many  directions  of  science  to  be  capable  of  conducting  a  modern  x-ray  labora- 
tory, will  be  a  high-priced  individual.  Unfortunately,  there  is  no  school  in  which 
x-ray  operation  is  taught  as  a  course  of  study  in  any  systematic  way,  and  the 
x-ray  operators  of  to-day  have  learned  their  craft  in  their  own  laboratories  and  in 
the  hard  lessons  of  personal  experience.  No  doubt  at  some  future  time  there  will 
be  chairs  in  the  schools  devoted  to  the  teaching  of  x-ray  science.  In  order  to  enter 
such  a  school,  when  one  is  finally  established,  it  will  be  necessary  for  the  applicant 
to  pass  preliminary  examinations  in  medicine,  physics,  chemistry,  and  electricity. 

Most  of  the  x-ray  operators  of  to-day,  in  order  to  earn  salaries  adequate  to  the 
work  they  do  and  their  mental  equipment,  must  work  in  their  own  laboratories, 
since  institutions  have  not  yet  come  to  realize  that  the  x-ray  operator  is  a  person 
entitled  to  the  largest  emoluments.  There  is  hardly  an  institution  x-ray  operator 
in  the  country  drawing  more  than  $200  per  month,  and  the  average  salary  is  prob- 
ably not  nearly  half  so  much  as  that. 

A  good  x-ray  equipment  in  a  large,  liberally  patronized  institution,  conducted 
at  least  in  part  for  pay  patients,  should  be  a  profitable  branch  of  the  institution, 
and  the  quality  of  work  done  by  the  x-ray  operator  will  be  the  gauge  of  the  profit, 
so  that  it  will  be  a  paying  investment  to  employ  an  operator  capable  of  doing  the 
highest  order  of  work. 

Let  us  now  proceed  with  a  very  brief  description  of  some  of  the  accepted  forms 
and  articles  of  equipment: 

EQUIPMENT  OF  THE  X-RAY  LABORATORY 

The  principle  apparatus  in  the  x-ray  room,  of  course,  is  the  current-producing 
appliance.  When  the  x-ray  was  first  exploited  many  years  ago,  the  static  machine 
was  used  to  produce  a  high-voltage,  low-amperage  current.  A  little  later  the  induc- 
tion coil  was  employed  for  the  same  purpose  with  indifferent  success,  and  then 
came  a  period  of  improvement  in  the  induction  coil,  until  thai  coil  achieved  a  suffi- 
cient size  to  create  a  current  of  sufficiently  high  voltage  to  jump  a  gap  of  from  12 
to  20  inches,  combined  with  a  sufficient  amperage  to  create  the  x-ray  in  the  tubes 
of  that  day's  manufacture.  From  that  day  to  this  the  competition  has  been  keen 
between  the  tube  makers  and  those  who  were  called  upon  to  furnish  apparatus 
sufficient  to  operate  the  tubes.  As  the  coils  of  that  day  were  improved  in  strength- 
ami  current-producing  power,  it  became  necessary  to  build  tubes  accordingly,  that 


448  OPERATION   OF   THE   HOSPITAL 

is,  with  a  progressively  high  vacuum  to  take  this  current,  and  this  friendly  compe- 
tition brings  us  down  to  two  or  three  years  ago,  when  the  so-called  interrupterless 
transformer  machine  was  first  produced  for  x-ray  purposes.  This  machine  is  a 
step-up  transformer  with  revolving  switch,  which  changes  the  direction  of  one  set  of 
the  alternating  waves,  giving  a  pulsating  unit  direction  of  current,  doing  away 
with  all  inverse  current  in  the  x-ray  tube,  and  producing  a  far  greater  volume  than 
it  is  possible  to  obtain  with  an  induction  coil.  Another  advantage  of  the  current 
thus  produced  is  the  fact  that,  coming  in  successive  waves,  it  strikes  the  anode  of 
the  tube  only,  producing  more  penetrating  rays. 

This  apparatus  consists  of  the  transformer,  with  core,  primary  and  secondary 
windings,  set  into  an  insulating  case;  a  switchboard,  provided  with  means  for 
bearing  the  strength  of  the  current  entering  the  primary  of  the  transformer,  and 
in  this  way  bearing  the  output  of  the  secondary.  The  switchboard  also  contains 
the  meters  for  measuring  both  the  strength  of  the  supply  current  and  the  high- 
tension  current  furnished  to  the  x-ray  tube,  and  the  switches  for  controlling  the 
motor  that  revolves  the  rectifying  switch.  On  the  switchboard  also  can  be  mounted 
the  regulating  devices  for  various  treatments  by  the  x-rays,  and  the  automatic 
time  switch  for  regulating  the  time  of  exposure. 

These  are  fundamental  principles  of  the  interrupterless  machine,  and  the  details 
differ  only  as  the  machine  is  built  by  different  manufacturers. 

This  form  of  x-ray  apparatus  is  practically  that  approved  for  modern  x-ray  work, 
and  the  old  form  of  induction-coil  machine  seems  to  be  now  relegated  to  the  realm 
of  x-ray  treatment,  which  requires  less  vacuum  in  the  tube  and,  consequently,  less 
energy  to  excite  it. 

The  Portable  or  Tesla  Coil. — This,  operating  directly  on  the  alternating  cur- 
rent, requires  no  mechanical  make  and  break  of  the  spark,  alternations  of  the 
current  serving  this  purpose,  and  it  differs  from  the  ordinary  induction  coil  in  that 
the  secondary  winding  is  inside  the  primary,  and  in  this  way  a  greater  inductive 
effect  is  obtained  and  a  current  of  higher  voltage  produced. 

For  light  x-ray  work,  and  for  treatment  where  a  heavier  coil  is  not  available, 
this  has  proved  satisfactory.  It  is  constructed  of  suit-case  size  and  arranged  so 
that  it  can  be  attached  to  the  ordinary  light  socket. 

The  next  important  piece  of  apparatus  in  the  x-ray  realm  is  the  table,  with  tube 
holder  and  protective  shield.  This  table  consists  of  an  upright  with  an  arm  carry- 
ing the  x-ray  tube  and  protective  shield  which  encloses  it.  This  arm  is  capable 
of  adjustment  in  vertical  or  horizontal  position,  and  at  the  same  time  the  tube  may 
be  set  at  any  angle  desired.  The  top  of  the  table  has  a  section  covered  with  material 
that  does  not  retard  the  passage  of  the  x-ray,  and  built  into  the  top  is  an  arrange- 
ment for  almost  instantaneously  shifting  the  plates,  so  that  after  one  exposure 
another  plate  which  has  been  protected  from  the  action  of  the  ray  will  be  brought 
into  the  position.  At  the  same  time  the  tube  is  automatically  shifted,  and  in  this 
manner  stereoscopic  effects  can  be  obtained.  The  top  of  the  table  may  be  tilted 
and  locked  at  any  angle  from  the  horizontal  to  the  vertical,  making  pictures  in  an 
upright  position,  so  essential  for  accurate  diagnosis  of  the  thoracic  and  abdominal 
cavities,  the  stand  also  being  provided  with  a  means  of  using  the  tube  underneath 
the  top  of  the  table  for  fluoroscopic  examination,  if  a  separate  apparatus  for  this 
purpose  is  not  provided.  It  should  be  possible  to  swing  the  tube-carrying  arm 
around  the  upright  to  take  a  picture  with  the  patient  on  the  ordinary  hospital  cart, 
which  may  be  wheeled  into  position.  In  selecting  a  table  of  this  character,  particu- 
lar care  should  be  given  to  ascertain  if  it  is  manufactured  in  such  a  way  that  the 
tube  may  be  accurately  centered  over  any  part. 


THK   X-RAY    DEPARTMENT  149 

Stereoscopic  Negatives. — A  great  help  in  an  accurate  diagnosis,  and  one  easily 
made  with  the  table  described,  is  the  Wheatstone  stereoscope.  This  consists  of 
metal  boxes  having  ground-glass  front,  against  which  the  negatives  are  placed,  the 
illumination  secured  by  electric  lights  behind  the  ground  glass,  and  provided  with 
switch  for  varying  the  intensity  of  the  light.  The  boxes  are  mounted  on  a  graduated 
track,  and  so  arranged  that  they  can  be  set  equidistant  from  the  center  or  approxi- 
mately at  the  same  distance  that  the  radiograph  was  taken,  that  is,  the  distance 
from  the  anode  in  the  tube  to  the  negative.  In  the  center  of  this  scale  are  two  mir- 
rors set  in  such  a  manner  that  as  the  observer  looks  into  the  mirrors  the  picture-  are 
blended,  appearing  in  their  natural  perspective.  In  this  way  the  location  of  for- 
eign bodies  is  more  easily  determined  and  a  more  natural  appearance  given  to  all 
negatives. 

In  studying  the  action  of  the  stomach  and  intestines  a  special  apparatus  may 
be  obtained,  so  that  the  course  of  the  test-meal  can  be  actually  followed.  This 
appliance  consists  of  a  lead-lined  box  which  completely  encloses  the  tube,  and  has 
an  arrangement  in  the  front  of  the  box  for  providing  an  opening  of  varied  size  and 
shape  through  which  the  x-ray  passes.  The  patient  is  placed  before  this  opening, 
and  between  it  and  the  fluorescent  screen  of  barium  platinocyanid,  which  fluoresces 
under  the  action  of  the  ray.  This  screen  is  covered  with  a  lead-glass  through  which 
the  ray  cannot  pass,  and  suitable  provision  should  be  made  to  protect  the  operator 
from  any  of  the  ray.  On  this  screen  the  course  of  the  food  can  be  followed  as  it 
passes  down  the  esophagus  to  the  stomach.  The  walls  of  the  stomach  are  outlined. 
showing  the  size  and  position,  the  presence  of  malignant  growths,  stricture  of  either 
the  esophagus  or  the  stomach,  whether  prolapsed  or  in  normal  position.  The 
results  make  it  possible  to  determine  the  length  of  time  required  for  passage  of 
food  through  the  pyloric  opening  into  the  duodenum  and  to  study  contractions 
of  the  stomach.     The  course  of  the  food  can  be  traced  through  the  duodenum. 

Practically  the  same  process  is  employed  in  outlining  the  colon  by  the  injec- 
tion method,  using  the  principles  of  the  high  rectal  enema.  Foreign  material  can 
be  traced  through  the  small  intestine,  and  this  form  of  procedure  can  be  employed 
also  to  a  limited  extent  in  locating  the  precise  point  of  invaginations,  strictures, 
and  other  obstructions.  The  fluoroscope  screen  is  also  used  to  a  limited  extent  in 
determining  the  functional  activities  of  the  heart,  systole  and  diastole,  and  their 
abnormalities. 

The  room  in  which  the  fluoroscope  screen  is  located  must  be  capable  of  trans- 
formation into  a  complete  dark  room,  so  that  the  eye  may  become  accustomed  to 
the  finer  shades  of  light  and  shadow  through  the  screen.  An  excellent  and  conve- 
nient arrangement  of  this  room  is  to  have  two  doors  with  a  vestibule  between  so  that 
outsiders  may  be  brought  in  without  letting  in  any  light.  Some  operators  use 
a  very  faint  blue  light  at  the  top  of  the  room,  with  push-button  or  cord  al 
the  end  for  turning  off  and  on  the  blue  light.  This  blue  lighl  can  be  used  for 
illuminating  the  room  to  a  certain  extent  without  changing  the  focusing  power 
of  the  eye. 

There  are  many  small  pieces  of  apparatus  designed  for  perfecting  the  x-ray  in 
one  shape  or  another.  Among  these  is  the  intensifying  screen,  which  reduces  the 
time  of  exposure  from  tit)  to  St)  pel'  cent,  by  means  of  the  llworeseenl  screen,  which 
is  placed  in  contact  with  the  film  of  the  plate;  the  pastilles  for  determining  the  dose 
of  the  ray  by  the  change  in  color  of  the  pastilles  exposed  to  the  action  of  the  ray, 
compared  with  a  definite  color  standard;  the  screen  for  filtering  the  ray  in  treat- 
ment work;  the  various  forms  of  localizer  for  fixing  definitely  the  location  of  foreign 

bodies,  more  especially  in  the  eye. 


450 


OPERATION    OF   THE    HOSPITAL 


Operator's  Protective  Devices. — Since  the  era  of  short  exposures,  measured  in 
seconds  instead  of  minutes,  the  damage  to  the  x-ray  operator  seems  to  have  dimin- 


x      re.  />^v       .suite 


Fig.  160. — X-ray  suite  for  small  hospitals. 

ished  vastly,  and  we  rarely  hear  now  of  x-ray  burns  to  the  operator,  or  x-ray  affec- 
tions of  the  eye,  or  any  part  of  the  operator's  person.     This  is  undoubtedly  due  to 


o     k    e 


Fig.  161.— X-ray  department  for  small  hospital.     A  most  convenient  plan. 

the  shortened  exposure.  However,  it  is  conceded  to  be  good  practice  to  surround 
the  operator  with  every  device  that  will  guarantee  his  safety  from  either  primary 
or  secondary  x-ray  influences. 


THE    .C-KAY    DEPARTMENT 


451 


The  first  of  these  protective  devices  is  the  cabinet,  sufficient  in  size  to  protect  the 
person  of  the  operator.  It  is  made  of  wood,  and  lined  with  lead,  with  peep  holes 
(if  lead-glass.  In  this  cabinet  the  manipulating  apparatus,  switches  and  so  on, 
must  be  contained.  The  location,  exact  size;  and  shape  of  this  cabinet  can  lie  made 
tn  depend  a  good  deal  on  the  topography  of  the  z-ray  rooms  and  the  arrangement 
of  the  major  apparatus.  The  main  point  is  a  sufficiently  large  cabinet  to  prevent 
not  only  the  entrance  of  the  primary  .r-rays,  but  those  secondary  rays  that  seem  to 


c=-   0  re  i?  i   c=>  <=>  f^ 
Fig.  162. — X-ray  department  for  large  hospital. 


come  from  all  sorts  of  directions — we  do  not  know  how.  Operators  are  disposed 
to  grow  careless  as  their  experience  demonstrates  what  seems  to  them  almost  an 
immunity.  Not  very  much  is  suspected  concerning  the  so-called  cumulative 
el'lei't  of  the  .(--ray  in  the  matter  of  it >  permanent  el'leet  mi  the  operator.  This 
field,  however,  is  practically  unexplored.  The  other  protective  devices  for  the 
operator  are  rubber  gloves,  rubber  shoes,  aprons,  lead-glass  goggles,  and  movable 
screen. 


452  OPERATION    OF   THE    HOSPITAL 

PLANS  OF  THE  X-RAY  SUITE 

The  accompanying  plans  (Figs.  160-162)  show  three  forms  of  x-ray  quarters, 
two  for  the  small  hospital,  in  which  practically  all  the  apparatus  must  be  housed 
in  one  room,  and  another  for  large  institutions  or  private  laboratories,  in  which 
there  is  sufficient  space  available  for  comfort,  ease  of  operation,  and  the  convenience 
of  patrons. 

The  possibilities  and  probabilities  of  the  x-ray  for  the  immediate  future  are  so 
great  that  those  who  are  planning  equipment  at  present  should  think  about  the 
near  future,  when  an  immense,  as  yet  unexplored  field  will  have  opened  up  to  the 
x-ray  in  diagnosis  and  treatment,  and  it  will  be  unwise  economy  to  limit  the  x-ray 
quarters  to  the  needs  of  the  present.  Even  small  institutions  will  find  that  their 
x-ray  laboratory  will  increase  their  income  immeasurably  by  giving  sufficient  space 
and  installing  sufficient  apparatus,  and  employing  intelligent  enough  operators  to 
do  all  of  the  things  with  the  x-ray  that  are  possible  even  to-day. 


PATIENTS'  RECORDS  AND  RECORD  KEEPING 

Before  we  can  intelligently  discuss  hospital  rceords  of  patients,  we  must  fix 
the  limitations  and  the  ambitions  of  the  institution  for  which  the  system  of  records 
is  intended.  If  the  institution  is  to  be  content  with  merely  treating  the  present 
illness  of  the  patient,  and  with  sending  him  out  well  if  it  can,  and  is  willing  to  close 
the  book  there,  then  hospital  records  are  not  a  very  serious  matter.  But  such 
limitations  are  not  to  be  countenanced  in  the  modern  hospital.  The  cure  of  dis- 
ease is  not  by  any  means  the  limit  to  which  the  service  of  a  hospital  may  as] lire, 
and  no  modern  physician  will  be  satisfied  to  go  along  from  day  to  day  making  merely 
temporary  marks  on  the  records  of  patients,  without  some  well-grounded  and  very 
definite  ambition  to  employ  these  records  at  some  future  time  in  an  educational 
way,  and  in  the  interest  of  the  science  of  medicine.  However  small  the  institution, 
it  will,  in  the  course  of  time,  pass  through  its  doors  intensely  interesting  cases,  and 
the  medical  men  who  give  service  in  an  institution  are  entitled  to  at  least  the  re- 
ward of  permanent  records  to  which  they  may  turn  back  for  use  as  the  years  go  by. 

In  discussing  patients'  records,  therefore,  we  may  fairly  assume  that  every 
institution  wants  to  avail  itself  of  the  best  systems  in  points  of  completeness,  brev- 
ity, and  simplicity  that  can  be  devised.  We  may,  therefore,  summarize  and  classify 
patients'  records  by  stages,  and  we  can  then  work  up  to  a  homogeneous  routine 
practice  in  record  making  that  will  be  of  real  and  permanent  service,  not  only  in 
the  immediate  present  and  for  the  benefit  of  the  patient  in  the  case,  but  to  the 
future  of  medicine  and  to  the  sick  for  all  time.  Experience  in  the  treatment  of 
disease  and  the  advances  in  the  practice  of  medicine  are  built  on  patients'  records. 
Let  us,  then,  assume  certain  fundamental  and  basic  necessities  in  the  records. 

First,  when  the  patient  comes  into  the  hospital,  there  must  be  a  history  of  the 
case  from  the  very  onset  of  the  disease  for  which  he  is  to  be  treated,  and  this  history 
contemplates  the  family  history  as  well  as  the  personal  history  of  the  patient. 
In  other  words,  the  history  of  a  case  means  the  life-story  of  the  patient — physically, 
mentally,  and  morally. 

Second,  we  must  have  the  examination  of  the  patient  at  the  bedside,  with  the 
physical  findings  of  the  physician  who  conducts  the  examination,  written  graphic- 
ally and  in  detail. 

The  modern  physician  is  never  content  in  this  day  to  rest  a  diagnosis  of  even  the 
simplest  case  upon  his  bedside  observations,  and  requires  the  aid  of  the  laboratory 
of  pathology.  Hence,  our  third  step  in  the  record  is  the  report  of  the  laboratory 
of  pathology,  and  the  value  of  the  examinations  in  the  laboratory  may  depend, 
at  least  in  some  measure,  upor.  the  physical  findings  and  vice  versa.  In  very 
modern,  efficient  institutions  there  is  a  routine  laboratory  practice  thai  includes 
at  least  a  complete  examination  of  the  urine,  and  a  complete  examination  of  the 
blood  as  a  part  of  the  routine  of  the  admission  of  the  patient,  and  in  these  institu- 
tions there  is  also  a  routine  examination  of  the  blood-pressure,  the  hemoglobin  con- 
tent, and  a  white  and  red  and  differential  blood-count. 

Fourth:  We  may  assume  now  that  we  have  as  accurate  a  diagnosis  of  the  case, 
with  all  the  reasons  therefor,  as  it  is  possible  to  make  without  further  observation 
of  the  patient;  and  our  next  step  will  be  a  chronicle  of  the  case,  written  partly  by  the 

453 


454  OPERATION"    OF   THE    HOSPITAL 

attending  physician  or  his  assistant,  the  intern,  and  partly  by  the  nurse  who  is 
taking  care  of  the  patient;  this  we  may  call  the  daily  routine  of  the  case. 

After  a  time  the  patient  develops,  perhaps,  some  definite  disorder,  and  it  is 
determined  to  perform  a  surgical  operation,  and  the  record  must  include  the  gross 
pathology  revealed  at  the  operation,  what  was  done  surgically,  how  it  was  done, 
and  what  was  found. 

Because  of  a  tendency  on  the  part  of  the  public  to  hold  surgeons  to  a  strict 
accountability  not  only  for  what  they  do  in  an  operation,  but  as  to  whether  or  not 
an  operation  should  have  been  performed,  some  institutions  have  adopted  a  form 
of  consent  to  be  signed  by  the  patient,  or  some  one  responsible  for  the  patient,  that 
shall  take  the  form  of  an  agreement  that  the  operation  is  necessary,  an  acknowl- 
edgment of  its  gravity,  and  waiving  damages  of  every  sort  in  the  event  of  an 
untoward  result ;  and  so  important  has  this  written  permit  for  surgical  interference 
become  that  we  may  accord  it  the  dignity  of  a  complete  step  in  the  patients' 
permanent  record. 

But  perhaps  some  tissue — a  tumor  or  other  growth — or  some  abnormal  con- 
dition may  have  developed  at  the  operation,  and  tissue  is  removed.  The  case, 
upon  close  investigation  of  the  pathologic  mass,  may  seem  plain,  but  the  modern 
practice  of  medicine  and  surgery  demands  that  tissue  removed  in  any  kind  of  sur- 
gical operation,  whether  major  or  minor,  shall  be  passed  through  the  laboratory 
of  pathology  and  examined  as  a  test  of  the  clinical  diagnosis  of  the  case.  We  have, 
then,  our  next  stage — the  postoperative  laboratory  report.  Following  the  opera- 
tion our  daily  routine  is  maintained,  and  if  the  patient  recovers  the  record  will 
continue  until  he  is  ready  for  discharge,  at  which  time  there  should  be  another 
thorough  examination  of  the  patient,  physical  at  the  hands  of  the  attending  phy- 
sician, and  pathologic  at  the  hands  of  the  laboratory  of  pathology;  at  least  the 
secretions  and  blood  must  be  examined  before  discharge  for  purposes  of  comparison. 

But  perhaps  the  patient  is  unfortunate,  and  does  not  recover.  Then  there  is 
the  report  of  the  autopsy. 

If  we  have  carried  out  all  these  routine  practices  conscientiously  and  faithfully, 
we  shall  have  an  accurate  report  on  that  patient's  case  from  beginning  to  end,  and 
it  remains  now  only  to  file  that  report  in  some  such  form  and  manner  as  will  make 
it  available  either  for  some  purpose  of  the  patient  at  any  future  time  or  in  the 
interest  of  medical  and  surgical  science;  and  this  brings  us  to  the  last  stage,  or  that 
of  indexing,  cross-indexing,  and  filing  of  patients'  records. 

HISTORY  TAKING 

A  great  many  physicians  in  private  practice  are  methodic  enough  to  request 
histories  of  their  private  cases,  and  many  of  them  take  these  histories  themselves, 
after  a  routine  fashion,  the  result  of  their  years  of  experience.  Most  men  abbrevi- 
ate their  histories,  in  a  measure,  to  accommodate  the  elements  of  time  and  space. 

In  the  general  hospital,  however,  the  taking  of  histories  devolves  upon  an 
intern,  or  even,  in  some  cases,  upon  an  undergraduate,  especially  in  those  hospitals 
affiliated  closely  with  medical  schools.  In  any  event,  the  history  is  taken  by  an 
inexperienced  man,  one  oftentimes  who  will  not  be  sufficiently  well  informed  in 
clinical  medicine  to  place  a  correct  value  on  a  point  that  may  be  developed  out  of 
his  questions,  and  because  of  this  fact  most  institutions  have  framed  for  them- 
selves a  routine  form  of  history  taking  which  may  be  printed  upon  a  card  for  the 
use  of  the  intern.  In  other  institutions  this  history-taking  record  is  developed  in 
the  form  of  history  sheets,  and  a  few  institutions  have  gone  a  step  further  still  by 


patients'  records  and  record  KEEPING  4.J0 

printing  their  history  sheets  in  parts  and  in  different  colors,  as,  for  instance,  a  sheet 
for  the  heart  findings,  one  for  the  gastro-intestinal  findings,  and  one  for  nervous 
manifestations,  and  so  on.  These  refinements  of  history  taking  are  matters  of 
taste  and  preference,  however,  without  very  much  to  recommend  them,  excepting 
possibly  the  ease  with  which  the  routine  may  be  enforced  because  of  the  carrying 
out  of  certain  of  these  details.  The  important  thing  is  the  range  of  questioning  to 
be  employed  and  developments  growing  out  of  those  questions  along  lines  that 
may  seem  promising  of  results  at  some  stage  in  the  proceeding. 

A  very  useful  form  of  history  questions,  and  one  in  practice,  with  very  slight 
variation,  in  most  of  the  large  general  hospitals,  is  subjoined: 

Scheme  for  History  Taking 
Date,  Name,  Age,  Occupation,  Civil  State,    Nationality,   Residence 

present  complaint 

1.  Pain. 

(a)  Location. 

(b)  Mode  of  onset — frequency  and  duration. 

(c)  Character — paroxysmal,  continuous,  dull  ache,  dragging,  lightning- 

like. 

(d)  Radiation — shoulder,  back,  leg,  penis,  scrotum. 

(e)  Has  intensity  increased  or  decreased  since  onset? 

(/)    Severity — severe  enough  to  go  to  bed;  effect  of  exercise. 

2.  Pulmonary. 

(a)  Dyspnea. 

1.  Constant  or  paroxysmal. 

2.  Exciting  cause  of  paroxysm. 

3.  Relieved  by  lying  on  back  or  sitting  erect. 
(6)  Cough. 

1.  With  or  without  expectoration. 

2.  Characteristics  of  expectoration — color,  blood,  etc. 

(c)  Pain — with  breathing.     (See  under  "1.  Pain.") 

(d)  Hoarseness. 

3.  Cardiovascidar. 

(a)  Palpitation. 

1.  Constant  or  paroxysmal. 

2.  Apparent  exciting  cause  of. 

3.  Accompanied  by  sensation  of  pain  in  left  arm,  back,  etc. 

4.  Accompanied  by  dyspnea. 
(6)  Edema — of  ankles  and  eyelids. 

(c)   Pain  in  precordium.     (See  under  "1.  Pain.") 

4.  Gastro-intestinal. 

(a)  Appetite. 
(6)   Pain. 

1.  Influence  of  food  upon  pain. 

2.  Number  of  hours  after  meals. 

3.  Tenderness  over  (region). 

4.  Character  of.     (See  under  "1.  Pain.") 


456  OPERATION    OF   THE    HOSPITAL 

(c)  Nausea. 

1.  Degree. 

2.  Time. 

3.  Relation  to  food. 

(d)  Vomiting. 

1.  Mucus,  blood,  food. 

2.  Taste  (sour,  bitter). 

3.  Time  and  relation  to  meals. 

4.  Contents  of  previous  day,  etc. 

5.  Type — projectile,  regurgitation,  etc. 

6.  Frequency. 

(e)  Belching — gas,  fluid. 

1.  Sour,  bitter,  rancid. 

2.  Associated  with  pyrosis  (heartburn). 

(/)    Dysphagia — subjective  sensation,  location,  pain. 
(g)  Bowels. 

1.  Constipation  or  diarrhea. 

2.  Frequency. 

3.  Character  of  feces — clay-colored  or  tarry  stools,  ribbon-shaped, 

odor,  etc. 

4.  Admixture  of  mucus  and  blood. 

5.  Pain  on  defecation. 

6.  Tenesmus. 

7.  Evidences  of  hemorrhoids. 

5.  Nervous. 

(a)  Headache — occipital,  frontal,  supra-orbital,  helmet. 

(b)  Ocular — ptosis,  strabismus,  disturbed  vision,  tension,  tenderness. 

(c)  Aural — tinnitus,  disturbed  hearing. 

(d)  Sensory — tingling,  numbness,  girdle  pain,  formication,  anesthesias. 

(e)  Tremors — at  rest,  intention. 
(/)  Paralyses. 

(g)  Vertigo. 

(h)  Gait — steppage,  ataxic,  spastic,  hemiplegic. 

(i)   Mentality — apathy,  irritability,  memory,  speech. 

6.  Genito-urinary . 

(a)  Pain.     (See  under  "1.  Pain.") 

(b)  Tenesmus  of  bladder. 

(c)  Changes  in  urine — quantity,  color,  cloudy,  bloody,  smoky. 

(d)  Passing  of  stone — gravel  or  sand. 

(e)  Relation  of  pain  and  burning  to  time  of  micturition — before,  during, 

or  after  micturition. 
(/)   Sexual  disturbances. 
(g)  Incontinence  of  urine  and  feces. 

7.  General. 

(a)  Fever. 

(b)  Chills. 

(c)  Night-sweats. 

(d)  Malaise. 

(e)  Thirst. 


patients'  records  and  record  keeping  !•">> 

(/)  Insomnia. 

(</)  Jaundice. 

(It)  Loss  in  weight — how  much  and  during  what  period  of  time? 

(i)  Epistaxis. 

PAST    HISTORY 

(a)  Any  antecedent  disease  like  present? 

(b)  Injuries  and  operations. 

(c)  Rheumatism,  scarlet  fever,  measles,  pertussis,  typhoid,  erysipelas, 

malaria,  etc. 
(r/)  History  of  gonorrhea  and  its  complications, 
(e)   History  of  syphilis — sore  on  penis,  sore  throat,  skin  eruption,  alopecia, 

miscarriages,  etc. 
(/)    Any    previous    gastro-intestinal,    cardiac,    pulmonary,    or    nervous 

symptoms. 
(g)  Habits — alcohol,  coffee,  tobacco. 

MENSTRUAL    HISTORY 

1.  Menses. 

(a)  When  commenced. 

(b)  Regularity. 

(c)  Type,  duration,  and  amount. 

(d)  (See  under  "1.  Pain.") 

(e)  Discharge. 

2.  Pregnancies. 

Complications  following. 

3.  Births. 

Complications  following. 

4.  Miscarriages. 

FAMILY    HISTORY 

1.  How  many  dead,  and  what  causes;  ages  at  dates  of  death. 

2.  Constitutional  organic  disease  in  family  and  near  relatives,  such  as  tuber- 

culosis, diabetes,  epilepsy,  insanity,  etc. 

LABORATORY  ROUTINE 

While  we  have  scheduled  the  physical  examination  as  the  second  step  in  the 
routine  of  the  patient,  must  institutions  vary  this  form  by  routine  laboratory  ex- 
aminations made  as  a  pari  of  the  admission  of  the  patient,  and  which  are  intended 
td  very  greatly  aid  the  diagnostician  when  he  comes  to  the  physical  examination 
df  the  patient;  most  physicians  whose  wqrk  in  the  hospital  is  of  sufficient  impor- 
tance to  justify  the  institution  in  catering  to  their  time  and  convenience  are  ex- 
tremely busy  men,  and  any  aid  to  be  accorded  them  at  the  hands  of  the  institution 

administration  is  in  the  interesl  of  patients  and  for  the  bettermenl  of  institution 
service.  The  physical  examination  will,  in  a  greal  majority  of  cases,  turn  upon 
the  laboratory  reports  that  confront  the  examiner  when  he  fust  sees  his  patienl 
in  the  ward,  these  examinations  having  been  made  immediately  upon  the  admission 
of  the  patienl .  and  the  reports  being  available  at  the  firsl  visil  of  the  physician. 


458 


OPERATION    OF   THE    HOSPITAL 


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PATENTS     KKC'OHDS    AND    HKCUHD    KEKI'ING 


401 


In  most  well-managed  hospitals  these  admission  examinations  will  include  a 
white  and  red  and  differential  counl  of  the  blood,  a  hemoglobin  report,  ami  a  repent 
of  the  blood-pressure,  and  in  nearly  all  of  the  institutions  thai  stand  for  modern 


462  OPERATION    OF   THE    HOSPITAL 

practice  the  intern  on  each  service  charged  with  the  preparation  of  the  patient  for 
the  advent  of  the  attending  physician  has,  as  a  part  of  his  equipment,  the  blood- 
counter,  the  hemoglobin  determinator,  and  a  blood-pressure  apparatus. 

Laboratory  Reports. — In  the  Michael  Reese  Hospital  a  new  system  of  charting 
laboratory  reports  has  been' adopted.  It  has  been  assumed,  as  a  basic  principle, 
that  the  fewer  sheets  used  for  this  purpose  the  better  would  be  the  results.  An 
attempt  to  concentrate  all  reports  and  at  the  same  time  to  allow  the  necessary 
flexibility  has  been  made  by  adopting  four  charts.  The  first  two  charts  are  in- 
tended to  fill  the  needs  of  the  ordinary  routine  work  on  any  cases  in  the  hospital. 
The  last  two  are  used  only  in  special  cases. 

Figure  163  shows  a  picture  of  the  blood  and  urine  chart  printed  on  pink  paper, 
so  that  the  visiting  physician  may  turn  to  it  easily.  In  both  of  these  are  printed 
the  headings  under  which  most  routine  examinations  fall,  and  at  the  same  time 
there  is  a  space  sufficiently  large  for  remarks  or  extra  findings. 

In  Fig.  164,  which  is  printed  on  blue  paper,  is  presented  a  record  of  gastric 
analysis,  the  examination  of  feces,  sputum,  exudates,  and  transudates.  The  same 
principle  of  having  headings  for  the  usual  findings  is  adopted  in  this  chart. 

Neither  one  of  these  charts  allows  of  extension  in  case  of  the  study  of  special 
diseases,  and  to  fill  this  need  very  flexible  graphic  charts  are  adopted. 

Figure  165  shows  a  very  simple  chart  in  which  practically  nothing  is  printed. 
At  the  left  hand  a  space  is  left  for  any  orders  or  any  findings  that  the  doctor  may 
wish  especially  emphasized.  It  may  be  in  the  case  of  diabetes  or  nephritis,  in  which 
the  correlation  between  the  diet  and  urinary  findings  are  studied;  it  may  be  in  a 
case  of  leukemia,  in  which  daily  variations  in  the  blood-count  are  wanted;  or,  in 
fact,  it  may  be  any  condition  at  all  in  which  special  work  is  wanted  and  the  course 
from  day  to  day  followed,  that  such  a  chart  is  valuable. 

In  Fig.  166  is  represented  simply  a  sheet  of  paper  containing  J-inch  boxes. 
This  is  especially  designed  for  graphic  charting,  and  its  uses  are  really  very  many. 
As  a  blood-pressure  chart,  as  a  means  of  studying  the  effect  of  drugs  on  the  pulse, 
or  of  diet  on  the  sugar  output  in  diabetes,  or  in  any  one  of  the  number  of  instances 
of  this  sort,  this  chart  will  show  its  value. 


PHYSICAL   EXAMINATION 

The  physical  examination  of  the  patient  is  the  business  of  the  attending  physi- 
cian, who,  on  the  free  wards  of  the  average  large  hospital,  yields  a  part  of  his  pre- 
rogative in  this  respect  to  some  efficient  senior  intern  or  member  of  the  house  staff, 
if  there  be  such,  and  the  attending  physician  contents  himself  with  checking  up  of 
intern's  examination,  unless  the  case  be  one  that  requires  a  closer  scrutiny. 

However  the  examination  may  be  made,  and  by  whom,  there  is  a  routine  form  of 
report  that  seems  by  common  consent  to  be  convenient  and  efficient,  beginning  with 
the  general  appearance  of  the  patient  as  a  whole,  and  then  proceeding  with  the 
anatomic  divisions  of  the  body  until  the  seat  of  the  disease  is  reached;  whereupon 
the  description  of  the  findings  is  entered  upon  exhaustively  and  in  detail.  This 
physical  examination  may  also  include  the  findings  of  one  or  more  of  the  specialists 
called  in  for  the  purpose  of  examining  more  minutely  into  special  phases  of  the  cases, 
as,  for  instance,  the  eye  man  may  have  been  asked  to  look  into  special  eye  involve- 
ments, or  the  neurologist  may  be  asked  to  make  an  examination  of  certain  suspected 
nervous  or  brain  manifestations  or  lesions,  and  these  findings  will  also  be  included 
in  the  recorded  physical  examination. 


PATIENTS     RECORDS   AND    RECORD    KEEPING 


463 


THE   DAILY   RECORD 

Naturally,  the  daily  record  of  the  patient  will  be  in  two  parts — first,  a  record 
of  the  scientific  observations  of  the  physician,  and  this  may  be  written  either  by  the 
physician  himself  or  by  the  intern  making  rounds  with  him,  and  should  include 
any  changes  that  may  have  occurred  in  the  patient's  condition  since  the  last 
visit,  and  also  include  any  radical  procedures  that  may  have  taken  place  in  his 
case,  with  the  date  at  which  the  record  is  set  down,  and  with  the  time  in  hours  and 
minutes,  if  possible,  at  which  any  special  thing  happened  to  the  patient  worthy 
of  record,  as,  for  instance,  a  transfusion  or  a  surgical  operation. 

There  need  be  no  special  form  or  sheet  for  the  daily  record  of  the  patient,  except- 
ing that  it  should  be  on  a  hospital  heading,  uniform  in  size  with  all  of  the  other 
sheets,  with  ruled  lines  horizontally,  and  with  a  vertical  date  line  on  the  left  mar- 
gin of  the  sheet.  The  value  of  this  daily  record  will  depend  upon  the  conscien- 
tiousness with  which  it  is  kept  up. 

NURSING  CHART 
The  patient's  nursing  chart  is  a  part  of  the  technical  training  of  the  pupils  in 
the  training-school  and  should  be  on  a  prescribed  form  and  very  strictly  adhered 
to,  not  only  in  the  interest  of  the  patient  and  his  progress,  but  in  the  interest  of 

MICHAEL  REESE  HOSPITAL,  CHICAGO 

CLINICAL  RECORD 


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Fig.  167. — Nursing  chart. 

the  training  of  the  pupil  nurses.  This  chart  should  include  the  name  of  the  patient, 
tlic  name  of  the  attending  physician,  the  name  of  the  intern  assisting  in  the  Case, 
and  the  nurse  who  is  taking  care  of  the  patient  and  who  is  responsible  tor  the 
chart,  and  if  more  than  one  nurse  participates  in  the  care  of  the  patient,  then  the 
name  of  the  nurse  should  be  set  down  at  the  point  of  record  of  the  thing  that  she  is 
reporting.  The  body  of  the  record  should  include  a  space  for  the  date  and  hour  at 
which  the  observation  is  made;  the  temperature,  pulse,  and  respiration;  a  place 
to  record  the  medicine  given  and  the  nourishment,  with  another  space  for  general 
remarks  not  enumerated;  and,  finally,  space  for  an  account  of  the  excreta,  urine 
and  feces,  and  at  the  bottom  of  the  chart  there  should  lie  a  space  in  which  the 
physician  may  write  his  orders  for  the  day.  In  some  well-regulated  institutions 
the  old  practice  is  still  in  vogue  of  having  a  separate  order  hook,  which  is  carried 


464  OPERATION    OF   THE    HOSPITAL 

about  with  the  attending  physician  on  his  rounds,  and  in  which  is  written  by  the 
physician  the  order  for  each  patient,  with  the  name  of  the  patient.  This  practice 
either  entails  the  copying  of  the  physician's  orders  so  that  it  may  become  a  part  of 
the  permanent  record  of  the  case,  or  it  becomes  necessary  to  omit  the  physician's 
orders  from  that  record,  which  is  extremely  undesirable,  because  no  complete  record 
can  be  kept  that  does  not  include  the  medicines,  nourishment,  and  special  orders 
given  by  the  attending  physician. 

These  nursing  charts  are  so  important  that  an  acceptable  form  is  given  on  p. 
463 ;  each  sheet  is  intended  to  include  two  lines  for  each  of  the  twenty-four  hours 
of  the  clay,  and  for  economy  of  space  both  sides  of  the  sheet  are  used,  the  printing 
being  the  same  on  both  sides,  the  head  of  one  side  becoming  the  foot  of  the  opposite 
side,  so  that  charts  need  not  be  taken  out  of  the  chart-holder  to  be  written  upon. 

PERMIT  FOR  OPERATION 

It  is  becoming  a  common  practice  of  some  people,  especially  the  poor  and  more 
ignorant  classes,  to  hold  surgeons  to  an  unreasonable  accountability  for  their  con- 
duct of  their  cases,  due  very  largely,  perhaps,  to  the  fact  that  so  many  untrained 
and  incompetent  men  are  attempting  to  do  major  surgery;  and  every  technicality 
is  resorted  to  to  make  a  case  against  the  best  of  surgeons,  if  the  case  happens  to 
terminate  badly  and  some  venal  lawyer  looking  for  a  fee  happens  to  gain  the  ear  of 
the  family  of  the  patient.  Many  times  the  patient  is  justified  in  his  wrath  over  the 
result  of  an  operation,  because  very  much  crude  work  and  a  great  deal  of  unneces- 
sary surgery  is  being  done.  It  isn't  these  cases  that  we  are  now  discussing,  however, 
but  the  surgical  cases  of  men  in  our  institutions  who  know  what  they  are  doing,  and 
who  have  done  the  right  thing  and  have  clone  it  well ;  and  in  such  cases  the  surgeon 
is  entitled  to  protection  from  venality  and  a  species  of  blackmail. 

For  a  long  time  such  protection  has  been  mooted,  and  a  good  many  methods 
have  been  devised  to  secure  it. 

The  Michael  Reese  Hospital  has  given  much  attention  to  this  question,  and  has 
finally  adopted  a  form  of  written  consent  to  be  signed  by  the  patient,  if  an  adult 
and  in  sound  mind,  and  by  the  nearest  responsible  relative  of  the  patient  if  the 
patient  is  a  child  or  mentally  incapacitated  to  decide  whether  or  not  an  operation 
shall  be  performed.  This  permit  form  has  been  submitted  to  some  of  the  best  law- 
yers, and  all  of  them  agree  that  it  has  immense  force  as  a  moral  deterrant,  and  some 
of  the  ablest  men  in  the  legal  profession  have  pronounced  it  a  legally  binding  instru- 
ment; at  any  rate,  since  it  became  the  routine  of  the  hospital  to  demand  a  written 
permit  preceding  every  surgical  procedure,  there  has  not  been  an  opportunity  to 
test  the  validity  of  this  permit  form,  because  no  case  has  ever  gone  into  court  against 
the  hospital  or  its  surgeons. 

When  this  permit  was  first  proposed  there  was  objection  to  it  on  the  part  of  some 
of  the  surgeons,  who  felt  that  it  would  frighten  patients  or  their  friends  to  the 
extent  of  making  them  refuse  an  operation.  The  results  have  not  borne  out  this 
fear,  and  when  it  is  explained  to  a  patient  or  a  relative  that  such  a  permit  is 
demanded,  even  in  the  very  simplest  case,  merely  in  order  for  the  institution  to 
be  absolutely  certain  that  no  one  is  going  to  be  operated  upon  without  his  or 
her  consent,  objections  have  fallen  away,  until  now  it  is  definitely  understood 
by  surgeons,  physicians,  patients,  and  the  public  that  the  hospital  will  not 
allow  any  one  to  be  operated  upon  without  a  written  consent,  not  even  if  all  the 
family,  including  the  patient,  express  a  willingness  to  have  the  operation  done. 

Occasionally  a  patient  will  be  brought  to  the  hospital  Avhose  physical  condition 
is  extreme,  and  likely  to  be  rendered  even  worse  by  any  such  mental  disturbance  as 


PATIENTS'    RECORDS   .VXD    RECORD    KEEPING  1<>"> 

a  proposal  that  he  or  she  sign  a  permit  for  a  surgical  operation,  and  ii  i-  occasionally 
proposed  that  some  member  of  the  family  be  allowed  to  sign  the  permit  instead  of 
the  patient,  although  the  patient  is  in  perfect  command  of  his  or  her  faculties.  But 
this  is  never  permitted,  even  in  the  extremest  case.  The  patient,  and  the  patient 
only,  must  say  whether  he  or  she  will  be  operated  on,  because  in  the  event  of  recovery 
the  patient  may  fall  back  upon  the  insistence  that  he  never  gave  his  consent  to  the 
operation,  and  that  no  one's  else  consent  served  the  purpose,  and  this  is  a  good 
legal  argument,  anil  lawyers  say  "would  hold  in  court." 

Occasionally  a  patient  is  brought  to  the  hospital  in  a  critical  condition,  perhaps 
from  an  injury  on  the  street,  and  requires  that  an  immediate  operation  be  performed. 
The  patient  may  be  unconscious,  and  no  friends  at  hand.  Perhaps  the  patient  is 
even  unidentified.  In  such  a  case  as  that  it  would  seem  that  every  legal  require- 
ment, and  certainly  every  moral  requirement,  would  be  fulfilled  if  the  case  were 
referred  to  the  superintendent  of  the  institution,  who  would  exercise  the  discretion 
of  allowing  the  surgical  operation  to  proceed;  and  in  such  a  case  a  written  statement 
should  be  made  a  part  of  the  record,  and  signed  by  the  superintendent  of  the  insti- 
tution, who  assumed  the  initiative,  setting  out  the  facts  in  the  case  and  stating  why 
it  was  necessary  that  the  operation  be  immediately  performed  without  the  routine 
written  consent  to  that  effect.  If  such  a  case  ever  got  to  court,  the  judge  and  jury 
would  at  least  be  thoroughly  convinced  that  the  institution  had  carefully  weighed 
the  whole  situation,  and  that  whatever  was  done  was  done  in  the  interest  of  the 
patient  after  mature  deliberation;  and  the  presentation  of  such  a  case  would  have  a 
very  great  moral  value  and  the  patient  would  not  have  suffered  at  all. 

This  permit  for  operation  is  signed  by  the  patient  in  any  language  that  he  or  she 
can  write,  and  the  signature  is  witnessed  by  at  least  two  persons. 

This  form  of  permit  is  made  up  in  books  of  two  hundred  sheets,  one  hundred  on 
white  paper,  which  serves  as  the  original,  and  one  hundred  on  pink  paper,  that  is 
used  for  a  carbon  copy.  After  being  filled  out  and  signed,  the  original  is  torn  out 
of  the  book,  and  is  attached  to  the  record  of  the  patient,  and  goes  to  the  operating- 
room  as  a  part  of  that  record,  and  it  is  the  routine  practice  not  to  allow  a  patient  to 
be  anesthetized  or  prepared  for  the  operation  until  the  permit  is  presented  to  the 
head  nurse,  or  until  a  written  waiver  from  the  superintendent  of  the  institution  is 
presented  as  a  substitute. 

The  form  of  this  permit  is  given  herewith: 


I,   the  undersigned, a  patient  at  the Hospit  al, 

hereby  certify  that  I  have  full  knowledge  of  the  operation  to  be  performed  upon  me  under  (he 

direction  of  Dr ;  that  I  have  given  and  do  hereby  give-  my  express  consent 

thereto,  and  in  consideration  of  the  performance  of  the  said  operation  by  said  Dr , 

and  in  further  consideration  of  the  facilities  therefore  granted  me.  by  the 

Hospital,  I,  the  undersigned,  do  hereby  release  the  said  Dr and  the  said 

Hospital  from  any  and  all  claim  of  any  kind  and  nature  that  1  may  now 

have  or  that  I  may  have  against  them  or  either  of  them  at  any  time  hereafter  as  the  result  ol  the 
said  operation,  or  because  of  the  same  or  because  of  anything  arising  in  connection  therewith. 


Witnessed  by: 


HISTORY  OF  OPERATION 
The  history  of  a  surgical  operation,  the  nature  of  the  procedure,  ami  the  gross 
pathology  of  the  case  will  be  of  value  as  a  permanent  record  of  a  patient  only  if  it  i- 


466  OPERATION    OF   THE    HOSPITAL 

written  out  immediately  after  the  operation  is  performed.  The  memory  of  a  sur- 
geon or  intern,  ( who  may  perhaps  be  operating  on  several  cases  in  the  same  day,  is 
too  unreliable  to  admit  of  any  delay  in  such  an  important  matter.  It  is  almost 
an  utter  impossibility  to  induce  surgeons  to  write  the  history  of  their  operations, 
and  there  seem  to  be  one  or  two  expedients  by  which  this  important  data  may  be 
had.  One  of  these  methods  is  to  have  the  history  of  the  operation  written  by  the 
surgeon's  assistant,  that  is,  usually  the  intern.  The  other  recourse,  and  one  which 
is  in  force  in  a  few  of  the  larger  institutions  of  the  country,  is  to  keep  a  stenographer 
in  the  surgical  suite  at  all  times  when  surgical  operations  are  going  on.  The  sur- 
geon who  has  completed  an  operation  can  tell  the  history  while  he  is  changing  his 
clothing,  and  will  almost  invariably  be  willing  to  do  so,  and  even  when  a  surgeon 
has  performed  several  operations  one  after  another  during  the  morning,  each  one  will 
be  so  fresh  in  mind  that  he  will  have  no  difficulty  in  dictating  a  sufficient  history  to 
entirely  and  acceptably  cover  the  case.  Such  a  history  as  this,  dictated  by  the  sur- 
geon, is  of  vastly  greater  value  than  when  it  is  written  by  an  intern,  first,  because 
the  intern  will  be  busy  all  day,  and  can  hardly  have  time  to  write  the  history 
until  night,  and  unless  there  is  some  special  incentive,  either  in  the  case  itself  or  in 
the  discipline  of  the  institution,  the  history  will  be  cut  so  short  that  its  value  will 
be  greatly  impaired. 

After  its  completion,  the  history  of  the  operation  may  either  be  attached  at 
once  to  the  rest  of  the  record  of  the  case,  or  it  may  be  sent  to  the  library  to  be  at- 
tached upon  the  discharge  of  the  patient.  Sometimes  patients  exercise  a  morbid 
curiosity  about  themselves,  and  even  where  there  is  no  intention  whatever  to  deceive 
them  as  to  what  was  done,  the  seriousness  of  the  operation  grows  as  a  patient  reads 
the  details  in  the  record,  and  in  some  cases  it  may  have  a  really  disturbing  effect, 
and  it  is  the  practice  of  some  surgeons  to  request  that  the  history  of  the  operation 
be  withheld  from  the  record  for  this  reason. 

The  form  of  the  history  of  the  operation  is  one  of  preference;  but  it  would  seem 
that  the  most  useful  and  immediately  available  form  is  a  graphic  story  step  by  step' 
of  what  was  done,  where  the  operator  went,  what  he  found  there,  and  what  he  did 
about  it.  The  story  would  seem  to  begin  with  a  statement  as  to  the  kind  of  anes- 
thetic employed,  whether  ether,  chloroform,  or  gas-oxygen,  and  the  time  consumed. 
The  preparation  for  the  operation  may  be  stated  as  "the  regular  routine  preparation," 
or  in  the  event  that  there  was  some  departure  from  the  routine  technic  of  the  insti- 
tution, it  ought  to  be  so  stated,  then  the  operation  ought  to  be  repeated  step  by 
step,  including  the  incision  in  the  skin,  and  information  as  to  whether  or  not  the 
same  knife  was  used  in  going  through  the  skin  and  making  the  necessary  subsequent 
incisions,  because  we  know  that  infections  may  occur  from  the  use  of  the  same 
knife;  the  kind  and  size  of  ligatures  and  sutures  must  be  stated;  if  considerable 
vessels  are  ligated  it  ought  to  be  so  stated,  and  if  a  nerve  of  consequence  is  disturbed, 
that  ought  also  to  be  mentioned,  and  the  nature  of  the  disturbance;  each  tissue 
passed  along  the  route  to  the  source  of  the  trouble  ought  to  be  at  least  mentioned, 
with  any  findings  out  of  the  normal;  then  the  operation,  that  is,  the  actual  remedial 
work,  ought  to  be  covered  in  detail,  the  removal  of  a  tumor,  its  general  appearance, 
color,  size,  its  topography,  its  relation  to  surrounding  tissues,  its  circulation  and 
nerve  supply,  the  character  of  its  pedicle,  and  its  origin,  the  technic  of  its  removal, 
and  then  quite  as  great  care  and  elaboration  will  be  necessary  in  leaving  the  field 
of  operation  as  in  entering  it. 

The  history  of  the  operation  ought  to  include  a  definite,  detailed  statement  as  to 
the  patient's  behavior  under  the  anesthetic  and  during  the  operation,  and  the 
condition  of  the  patient  when  put  to  bed. 


PATIENTS'     RIX'OKDS    AND    KKCOIfD    KI.I.M   ...  I'., 

FILING  AND  INDEXING  OF   RECORDS 

The  discharge  of  the  patient  is  a  rigid  piece  of  technic.  Naturally,  the  physi- 
cian in  charge  of  the  patient's  welfare  ought  to  say  when  the  patient  is  ready  to  go 
home,  and  thai  order  should  be  expressed  by  the  physician  in  his  own  handwriting 
somewhere,  and  the  besl  place  for  the  order  of  discharge  is  on  the  small  admission 
card  which  accompanied  the  patient  to  the  bed  to  which  he  was  assigned,  and  which 
has  been  a  part  of  his  record  all  through  the  institution,  and  under  the  heading 
provided  for  "discharge."  The  next  step  is  the  gathering  of  the  clothes  and  what- 
ever valuables  tin'  patient  may  have  had  on  entering  the  hospital.  There  is  a 
clothes  list  and  a  list  of  the  valuables,  and  these  should  be  taken  to  the  business 
office  of  the  institution  at  the  same  time  with  the  completed  record  of  the  patient. 
The  clothes  list  is  checked  by  the  office,  so  that  the  orderly  may  get  the  clothes 
from  the  locker-room  custodian,  and  the  valuables  are  turned  over  to  the  head 
nurse  on  surrender  of  the  receipt. 

It  is  the  record  only,  however,  that  we  have  now  to  deal  with,  the  balance  of 
the  technic  being  followed  more  in  detail  under  the  heading  of  the  business  office 
and  its  affairs.  The  small  admission  card  attached  to  the  record  is  stamped  with 
the  day  and  hour  of  the  discharge  of  the  patient,  and  may  then  be  regarded  as  a 
closed  incident  in  the  affairs  of  the  institution,  and  it  is  immediately  sent  to  the 
record  library  for  its  final  filing;  the  large  admission  card,  which  has  remained  in 
the  office,  being  used  to  close  the  patient's  account  in  the  books. 

A  great  number  of  systems  have  been  tried,  and  nearly  every  institution  in  the 
country  that  makes  any  pretense  to  keep  correct  records  has  evolved  some  system 
of  its  own  for  the  preservation  of  its  records  in  such  manner  that  they  can  be 
drawn  upon  for  use  for  any  purpose.  Without  going  into  these  various  systems  am  I 
their  strong  points  and  weaknesses,  we  may  launch  at  once  upon  a  very  brief  dis- 
cussion of  that  general  system  which  seems  to  meet  with  almost  universal  favor, 
either  in  whole  or  in  some  modified  form  applicable  to  special  situations. 

There  is,  first,  the  small  admission  card  which  we  have  carried  all  the  wax- 
through,  and  which  now  becomes  the  index  card  filed  alphabetically  under  the  name 
of  the  patient,  so  that  inquiring  friends  of  the  patient  himself  may  at  any  time  have 
access  to  his  record  by  means  of  his  admission  card  and  its  accompanying  number. 

Then  there  is  the  topic  of  the  disease  from  which  the  patient  suffered,  pneumonia, 
for  example,  and  a  card  is  filed  in  the  disease  section  of  the  index  in  that  way: 

PRINCIPAL  DISEASE  OR  OPERATION 


COMPLICATIONS 


NAME  NO. 

DATES  AGE  DR. 

CONDITION 


468  OPERATION    OF    THE    HOSPITAL 

Third,  there  is  a  card  indicating  the  organ  of  the  body  affected,  that  is,  the 
organ  which  was  the  chief  seat  of  the  patient's  disease.  In  the  illustration  which 
we  have  already  taken  the  organ  would  be  the  lungs,  so  that  the  third  card  is  filed 
under  the  heading  of  "lungs,  disease  of": 

ORGAN  AFFECTED 


PRINCIPAL  DISEASE 

NAME  AGE  NO. 

DATES  DR. 

CONDITION 


And  there  is  finally  a  fourth  card  which  may  be  used  to  describe  any  compli- 
cation of  the  disease  which  would  seem  to  have  a  direct  bearing  on  the  case.  Let 
us  carry  along  our  illustration  and  say  there  was  an  effusion,  so  that  a  card  would 
be  made  out  for  "effusion,"  complication  of  pneumonia: 

COMPLICATION 


PRINCIPAL  DISEASE 

NAME  AGE  NO. 

DATES  DR. 

CONDITION 


If  this  index  system  is  faithfully  carried  out,  we  will  have  in  the  card  index 
all  the  information  we  will  ever  want  concerning  the  patient,  and  by  means  of  the 
name  and  number  have  access  to  the  record  which  is  filed  away,  and  in  addition  to 
that  we  shall  have  a  means  of  directing  the  inquirer  to  whatever  he  wants  for  literary 


patients'  records  and  record  keeping  469 

purposes.     Let  us  say,  for  instance,  there  is  in  preparation  a  paper  on  pneumonia, 

and  all  the  literature  that  the  house  affords  on  the  subject  of  pneumonia  will  In- 
required;  the  card  index  will  give  a  list  of  the  pneumonias  covering  the  whole  period 
of  the  hospital's  existence.  But  suppose  the  information  desired  covers  all  diseases 
of  the  lungs;  then,  under  the  heading  of  "lungs"  these  pneumonias,  as  well  as  all 
other  pulmonary  diseases,  will  be  found.  But  let  us  suppose  that  it  is  none  of  these 
that  the  inquirer  seeks,  but  that  he  is  writing  on  the  subject  of  effusions  of  various 
sorts  and  in  various  localities  in  the  body.  Then,  under  that  heading,  he  will  find 
the  "effusion"  as  a  complication  of  pneumonia  recorded  in  this  particular  case.  It 
is  not  necessary  that  these  second,  third,  and  fourth  index  cards  shall  go  into  the 
matter  at  great  length,  but  that  they  shall  merely  refer  to  the  case  as  shown  in 
the  illustration.  Sometimes  the  case  may  require  half  a  dozen  cross  indices,  and 
these  ought  to  be  carried  out  faithfully,  if  the  medical  men  in  the  institution  are 
to  have  the  best  possible  use  of  the  literature  accumulated  as  the  years  go  by. 

For  instance,  let  us  take  just  one  case  and  see  where  it  will  lead  to :  We  have  John 
Smith  coming  to  the  hospital  with  an  advanced  case  of  appendicitis  which  has 
ruptured,  and  a  peritonitis  has  already  commenced.  The  patient  is  operated  upon, 
and  in  the  course  of  two  or  three  days  develops  a  hypostatic  pneumonia.  The 
patient  is  constantly  losing  ground,  and  finally  develops  an  empyema,  and  eventu- 
ally dies,  largely  because  his  resistance  has  been  destroyed  by  the  diseases  and 
their  complications  from  which  he  had  suffered.  Now7,  there  are  many  things  of 
importance  in  this  case  that  should  be  preserved  in  the  records.  Naturally, 
there  wall  be  a  card  for  the  appendicitis,  and  a  cross-card  for  the  peritonitis,  another 
card  for  the  pneumonia,  and  still  another  card  for  the  empyema;  yet  all  of  these 
diseases  have  been  complications  of  the  appendicitis,  and  should  be  scheduled 
as  such  complications,  although  they  are  definite  diseases,  and  might  have  been 
an  original  lesion. 

In  some  institutions  the  records  are  kept  with  a  view  to  annual  reports,  so  that 
a  long  list  of  diseases  may  be  published  as  a  part  of  the  showing  of  the  hospital  for 
the  year,  but  there  is  no  other  reason  why  the  whole  index  system  of  the  institu- 
tion should  be  warped  for  a  purpose  that  can  be  met  in  the  course  of  two  or  three 
hours'  work  by  going  over  the  superintendent's  diary,  which  gives  the  diagnosis 
of  the  case  at  the  end  of  the  discharge  column. 

In  some  of  the  large  general  hospitals  there  is  an  attempt  to  maintain  a  separate 
card  index  of  records  for  each  department — one  for  medicine,  one  for  surgery,  one 
for  pediatrics,  one  for  maternity,  and  so  on.  It  would  seem,  however,  that  this  sys- 
tem may  cause  great  confusion.  For  instance,  a  child  is  brought  to  the  hospital 
and  admitted  to  the  medical  department.  In  the  course  of  time  he  develops  a 
surgical  disease  and  is  operated  upon.  Some  nose  or  throat  lesion  may  supervene, 
and  the  patient  is  operated  upon  again  in  another  department.  So  that  we  would 
have  this  patient  running  through  several  departments  of  the  hospital,  and  in  cadi 
department  there  would  be  an  index  and  cross-index,  and  thus  the  system  could  be 
elaborated  to  a  point  of  topheaviness  that  would  not  be  carried  out,  and  hence  would 
be  worthless.  The  maternity  department  is  just  a  little  different,  and  the  modern 
up-to-date  obstetricians  are  socager  in  their  acquirement  of  special  knowledge  based 
upon  large  series  of  cases  that  it  would  almost  seem  desirable  to  maintain  for  them 
a  separate  index  which  need  not  be  pathologic  at  all,  as,  for  instance,  they  may  want 
an  index  of  placentas,  an  index  of  pelvic  measurements,  or  an  index  of  blood 
examinations  of  mother  and  child.  Especially  is  this  the  case  just  now,  when 
the  obstetricians  are  invading  new  fields  of  investigation,  and  they  are  entitled 
to    all    the    help    that    the   institution   can   give   them    in    their   researches.       But, 


470 


OPERATION    OF    THE   HOSPITAL 


barring  this  one  department,  there  seems  no  legitimate  reason  why  the  indexing  of 
records  ought  to  make  any  complications  excepting  as  outlined  above. 

In  some  institutions  color  cards  are  kept,  one  for  the  organ,  one  for  the  com- 
plication, and  so  on.  But  these  also  would  seem  to  be  superfluous,  and  they 
merely  serve  the  purpose  of  littering  up  the  system. 

There  should  be  four  compartments  in  the  filing  cabinets  or  rather,  perhaps, 
four  independent  cabinets — one  for  the  name  of  the  patient,  one  for  the  disease, 
one  for  the  organ  affected,  and  one  for  complications. 

Boxing  of  Records. — The  keeping  of  records  permanently  is  a  matter  that 
has  caused  a  great  deal  of  trouble  and  is  not  yet  settled.  There  are  objections  to 
every  system  in  use;  the  question  is,  Which  one  seems  to  present  the  fewest  objec- 
tions?    In  the  large  Eastern  institutions  the  records,  as  a  rule,  are  bound  and  filed 


Fig.  168. — Record  box. 


in  book  form,  and  so  are  kept  neatly,  and  with  a  view  to  ready  reference;  but  it 
may  be  very  seriously  doubted  whether  this  system  is  one  best  calculated  for  the 
convenience  of  the  medical  men  working  in  the  institution.  For  instance,  a  patient 
comes  to  the  hospital  a  second  time,  and  the  old  record  is  wanted,  not  only  for  the 
purpose  of  reference  at  the  moment  of  admission,  but  as  a  continuous  reference 
during  the  patient's  stay  in  the  institution;  in  such  a  case  it  would  seem  necessary 
to  attach  the  old  record  to  the  new,  and  so  keep  them  together;  the  bound-book 
form  would  not  lend  itself  to  this  convenience,  and  the  difficulties  presented  in 
such  a  case  would  seem  to  be  a  sufficient  advocate  of  an  independent  resting-place 
for  each  patient's  record.     Figure  168  illustrates  such  a  convenient  record  box. 

The  sheets  of  the  record  in  fastening  should  be  placed  in  the  order  of  their 
occurrence  in  the  patient's  history.  The  history  sheet  first,  because  that  is  taken 
first,  the  physical  examination  second,  the  laboratory  findings  on  admission  next, 


patients'   RECORDS  AND  RECORD   KEEPING  471 

the  first  page  of  the  nursing  chart  to  follow,  and  then,  in  the  regular  order,  the  inci- 
dents  of  the  case.  The  individual  records  are  fastened  together  by  wire  staples 
and  are  placed  in  boxes,  100  in  a  box,  in  numeric  sequence,  so  thai  any  record 
can  he  found  in  a  moment  by  simply  running  over  the  corners  of  the  100  records. 

Who  Shall  Have  Access  to  Records? — The  question  of  who  may  have  access 
to  the  records  of  a  patient  is  an  ever-perplexing  one  in  every  institution.  In  some 
hospitals  any  one  may  see  a  patient's  record  and  use  it  in  any  way  he  see-  fit :  and 
in  most  places  the  members  of  the  medical  staff  may  have  access  to  any  record  I  hey 
care  to  consult  without  reference  to  the  purpose  of  the  consultation;  but  in  carefully 
conducted  institutions,  especially  in  the  large  cities,  where  there  are  complications 
having  to  do  with  corporations,  such,  for  instance,  as  injuries  to  patients  and  illness 
caused  by  conditions  of  work,  there  is  a  very  definite  rule  prescribing  who  may  have 
access  to  records  and  the  purposes  for  which  records  may  be  consulted. 

The  business  of  a  patient  is  supposed,  in  the  ethics  of  the  medical  profession, 
to  be  sacred,  and  no  physician  of  repute  will  discuss  his  patient's  private  affairs, 
including  his  physical  state,  with  any  one,  and  especially  with  any  person  likely 
to  make  hurtful  use  of  the  information.  It  would  seem  that  a  hospital  should  occupy 
the  same  relative  position  toward  a  patient,  that  is,  that  the  affairs  of  a  patient 
are  sacred  to  the  institution,  and  that  they  should  be  preserved  privately  and 
kept  inviolable,  except  on  the  definite  order  of  a  court  that  they  be  revealed. 

A  patient  has  a  right  to  his  own  record  and  to  the  use  of  its  contents,  notwith- 
standing some  physicians  take  the  ground  that  a  patient  who /manges  doctors  has 
no  right  to  a  record  of  a  former  illness  as  kept  for  or  by  some  other  physician — in 
other  words,  that  the  physician  is  not  in  duty  bound  to  give  any  information  for 
the  benefit  of  some  other  doctor.  It  would  seem  that  a  broader  view  is  that  the 
patient  is  entitled  to  whatever  information  may  be  necessary  in  the  treatment  ot 
his  illness,  notwithstanding  the  fact  that  he  may  have  changed  physicians  or 
changed  hospitals.  Some  physicians  act  upon  the  presumption  that  hospital 
records  belong  to  them  for  any  purpose  for  which  they  care  to  use  them,  whether 
the  use  be  in  the  patient's  interest  or  in  the  interest  of  some  corporation  which  the 
patient  is  suing.  The  humanitarian  view,  however,  and  the  fairer  view  would 
seem  to  be  that  the  attending  physician  of  the  patient  has  no  more  right  to  the  use 
of  a  record  for  improper  purposes  than  anybody  else  has,  and  it  goes  without  say- 
ing that  the  use  of  a  record  against  a  patient  for  legal  purposes  is  an  improper  one. 
and  ought  not  to  be  tolerated  by  any  institution  or  allowed,  either  at  the  hands  of 
a  member  of  its  medical  staff,  or  an  outside  physician,  or  an  attorney  of  a  corpora- 
tion. There  are  a  great  many  hospitals  in  the  country  that  allow  themselves  to 
be  used  by  corporations,  and  not  a  few  have  definite  contracts  with  corporations 
for  the  care  of  patients  that  they  may  send,  one  of  the  clauses  of  which  contracl 
prescribes  that  the  corporation  may  have  its  own  physician  in  attendance  on  a 
patient,  or,  in  case  the  patient  has  his  own  physician,  that  the  corporation  may  have 
access  to  the  patient  at  any  time.  This  means,  in  plain  parlance,  that  the  cor- 
poration has  a  right  to  the  iniquitous  and  criminal  practice  of  forcing  settlements 
out  of  sick  people,  a  position  wholly  untenable,  and  one  that  is  a  public  scandal  in 
many  parts  of  the  country  and  in  many  institutions.  In  the  besl  conducted  hos- 
pitals it  is  the  practice  to  refuse  admission  to  corporation  lawyers,  corporation  doc- 
tors, and  corporation  claim  agents  of  whatever  character  or  degree  of  eminence; 

and  in  these  institutions  it  is  definitely  understood  thai  the  patient  is  in  the  care 

and  sacred  custody  of  the  institution,  with  a  view  to  the  curing  of  his  illness  or  the 

healing  of  his  hurt,  and  that  the  transaction  of  any  business  of  whatever  nature 
will  not  he  permitted  at  any  time  during  the  patient's  soj ourn  in  the  institution, 


472  OPERATION    OF   THE    HOSPITAL 

without  his  explicit  consent  and  wish  expressed  at  a  time  when  he  is  in  perfect  com- 
mand of  his  faculties  untempered  by  bodily  or  mental  pain. 

This  subject,  however,  brings  up  another  delicate  point,  that  is,  How  far  is  it 
the  duty  of  an  institution  to  go  in  connivance  with  a  patient  to  perpetrate  a  fraud? 
There  are  a  great  many  people  who  live  by  their  wits,  that  is,  by  the  bringing  of 
damage  suits  against  corporations  for  personal  injuries,  with  a  view  to  a  settlement 
for  some  small  account  to  be  divided  with  a  pettifogging,  conscienceless  lawyer 
whose  livelihood  is  gained  in  the  same  way.  For  instance,  a  patient  spends  a  sea- 
son in  the  hospital,  leaves  the  institution,  and  brings  suit  against  a  corporation  on 
the  ground  of  personal  injury,  citing  his  stay  in  the  hospital  as  the  expression  of  this 
injury.  Cases  are  almost  numberless  in  which  patients  have  sued  corporations 
for  injuries  that  existed  years  before  the  alleged  accident  occurred,  and  the  records 
of  the  hospital  would  show  such  previous  injuries  or  illness.  There  was  a  case  in 
point  not  long  since  in  which  the  corporation  counsel  for  a  large  city  requested  a 
record  of  a  patient,  which  was  refused  on  the  ground  that  the  record  was  proposed 
to  be  used  in  a  legal  interest  inimic  to  the  patient;  in  other  words,  to  defeat  the 
patient's  attempt  to  gain  a  damage  suit  for  personal  injury.  The  corporation 
counsel  appreciated  the  institution's  view-point,  but  made  the  counter  proposal 
that  if  he  were  able  to  show  that  the  patient  had  sued  five  different  corporations 
at  various  times  for  the  same  injury,  and  that  the  injury  itself  had  occurred  long 
before  any  of  the  suits  had  been  brought,  then  the  institution  ought  to  waive  its 
point  and  reveal  the  contents  of  the  record.  The  attorney  for  the  hospital  agreed 
to  this  contention,  the  use  of  the  record  was  allowed,  and  the  patient's  case  thrown 
out  of  court  with  severe  censure  by  the  sitting  judge. 

There  is  no  doubt  that  the  record  of  a  patient  ought  to  be  at  the  disposal  of 
medical  men  for  the  purpose  of  their  literature,  and  such  use  of  records  can  be 
permitted  very  easily,  even  to  the  extent  of  allowing  the  physician  to  remove  the 
record  from  the  hospital  by  the  mere  routine  signing  of  a  receipt  for  the  record, 
and  such  receipt  ought  to  state  the  number  of  pages  in  the  record,  not  with  a  view 
to  inhibit  the  mutilation  of  records,  because  we  have  a  right  to  assume  that  no 
reputable  physician  would  mutilate  a  record  in  his  keeping,  but  in  order  that  one 
or  more  pages  may  not  be  lost  during  its  absence.  But  physicians  should  not  have 
the  use  of  records  for  legal  purposes  under  any  circumstances  whatever.  That 
use  of  a  record  ought  to  be  confined  to  the  institution  itself.  In  other  words,  if  a 
physician  who  has  treated  a  patient  in  the  wards  of  the  hospital  is  asked  to  testify 
in  a  subsequent  action  at  law,  it  ought  to  be  his  duty  to  state  definitely  that  he 
does  not  remember  the  facts  of  the  case,  provided,  of  course,  that  is  the  truth,  and 
that  these  facts  are  in  the  custody  of  the  hospital,  and  that  the  contestants  should 
take  the  matter  up  with  the  institution  authorities.  If  it  has  been  a  private  patient 
of  the  physician  the  case  is  somewhat  mitigated,  but  in  such  a  case  the  doctor  will 
probably  have  his  own  private  record  with  which  to  refesh  his  memory,  and  if  he 
has  not,  then  the  case  has  not  been  sufficiently  his  own  to  justify  his  use  of  the 
records  independent  of  the  institution. 

One  of  the  nuisances  of  the  modern  medical  record  library  is  the  constant 
requests  for  copies  of  records,  and  the  question  is,  Is  the  institution  obliged  to  fur- 
nish these  copies,  and,  if  so,  should  there  be  a  charge  for  them?  In  nearly  every 
case  of  requests  of  this  sort  the  record  is  wanted  for  purely  medical  purposes,  and 
it  is  wanted  usually  for  the  use  of  some  physician  who  is  treating  a  present  ill- 
ness of  the  patient;  so  that  what  is  really  wanted  is  the  diagnosis  in  the  previous 
illness,  an  account  of  any  surgical  operation  that  may  have  been  performed,  and 
usually  a  very  short  synopsis  of  the  case  dictated  by  some  medical  authority  of  the 


PATIENTS     RECORDS    \\i>    aECORD    KEEPING 


17:; 


institution  will  servo  all  of  the  purposes;  if  a  complete  record  is  wanted,  however, 
it  would  seem  that  the  patient  ought  to  pay  at  least  for  the  time  of  the  clerk  in 
preparing  it  and  for  the  trouble  incident  to  the  copying  of  the  record. 

A'-ray  Records — How  Kept.  -X-ray  records  are  rather  different  from  other 
records  of  patients.  They  are,  as  a  rule,  pictures  of  localities  of  the  human  body, 
and  usually  well-defined  localities,  such,  for  instance,  as  a  shoulder,  hip-joint,  kid- 
ney, bladder,  gall-bladder,  or  head,  and  it  would  seem,  therefore,  thai  there  may  be 
two  index  cards  only,  one  giving  the  patient's  name,  so  that  the  plate  or  print  may 
lie  found,  and  the  other,  the  locality  taken;  this  for  purposes  of  the  literature  and  to 
enable  medical  men  to  study,  if  they  like,  a  series  of  plates  of  some  particular  local- 
ity. 

There  is  also  an  anatomic  index  carried  along  with  the  above,  which  will  make 
it  possible  for  the  librarian  to  pick  out  sectional  plates,  so  that  the  physician  or 
surgeon  can  study  a  region  and  compare  normal  plates  with  possible  abnormalities 
which  he  is  studying.  This  index  is  carried  along  with  and  becomes  a  part  of  the 
other  index. 

Following  is  a  schedule  under  which  it  would  seem  that  nearly  any  x-ray  plate 
could  be  indexed,  and  in  daily  use  this  schedule  has  been  found  to  meet  practically 
all  the  requirements,  and  permits  of  an  easy  and  rapid  finding  of  whatever  is 
wanted. 

INDEX  FOR  X-RAY  PLATES 


1 .  .1  rli  ries  and  Veins. 

(a)  Aneurysm. 

2.  Arthritis. 

3.  Bismuth  Ti'st-mcals. 

(a)  Colon. 

(6)  Small  intestine. 

(c)  Stomach. 

(d)  Rectum. 

4.  Calculi. 

(a)  Choleliths. 

(6)  Enteroliths, 

(c)  Phleboliths. 

(rf)  Renal. 

(c)  Urethral. 

(/)  Vesical. 

5.  Defects  and  Deformities. 

(a)  Cervical  rib. 
ill)    Scoliosis. 

(c)   Spina  bifida. 

6.  Dislocations. 

Acquired: 

(a)  \nklc  mid  toes. 

(b)  Elbow. 

(c)  Hip. 
(it)  Jaw. 
(e)    Knee. 

i.h   Shoulder. 

o/i   \\  t'M  and  fingers. 
Congenital. 

7.  Expi  rimental. 

8.  Foreign  Bodies. 

i  a  i   Abdomen. 

(b)  Foot, 
(i      Hand. 

o/i  Miscellan is. 


9.  Fractures. 

(a)  Clavicle  and  scapula. 

(6)  Carpus,  metacarpus,  phalanges. 

(c)  Femur. 

(d)  Humerus. 

(e)  Pelvis. 

if)    Radius  and  ulna. 

(g)  Ribs. 

(h)  Skull  and  face. 

(i)   Tarsus,  metatarsus,  phalanges. 

if)    Tibia  and  fibula. 

10.  Heart  ami  Pericardium. 

11.  Intestines. 

12.  Miscellaneous. 

13.  Mastoid  Disease. 

14.  Normal. 

(a)  Abdomen: 

Kidney  region. 

Middle  region. 

Pelvis. 
(6)   Bones: 

Clavicle  and  scapula. 

Femur. 
Humerus. 
Tibia  and  fibula. 

Radius  and  ulna. 

(c)  Chest  : 

Lungs  and  heart. 

(d)  Heart: 

Sinuses. 

Mastoid. 
Sphenoid,  etc. 

(c)    Intestines. 

(J)   Joints 

\nkle  and  foot. 

Elbow. 

Knee. 

Shoulder. 

Spine. 

Wrist  and  hand. 

5t  i  imach. 


474 


OPERATION    OF   THE   HOSPITAL 


15.  Osteomyelitis,  non-tuberculous. 
(a)  Bones  of  face. 
(6)  Lower  extremities, 
(c)   Upper  extremities. 

16. 


17.  Pleura. 

(a)  Empyema. 

(b)  Pneumothorax. 

(c)  Serous  effusion. 

18.  Stomach. 

(a)  Dilatation. 
(6)  Gastroptosis. 

Sinus  Disease, 
(a)  Antrum. 
(6)   Frontal. 

(c)  Hemisinusitis. 

(d)  Pansinusitis. 

(e)  Sphenoiditis. 


19 


20.  Syphilis. 

21.  Tumors. 

(a)  Brain. 

(6)  Carcinoma. 

(c)  Exostosis. 

(d)  - 


22.  Tuberculosis. 
Soft  tissues: 
(a)  Lungs. 
(6)  Serous  membrane. 

(c)  Kidney. 

(d)  Glands. 
Bones  and  joints: 

(as)  Bones  of  face. 
(6)   Hip. 

(c)  Lower  extremity. 

(d)  Upper  extremity. 

(e)  Spine. 


Abdomen: 

Gall-bladder  region. 

Kidney  region. 
Ankle. 
Arm. 
Chest. 

Clavicle  and  scapula. 
Forearm. 
Foot. 

Head: 

Lateral. 
Mastoid. 
Posterior. 
Anterior. 


ANATOMIC  INDEX 

Hip. 

Knee. 

Leg. 

Pelvis. 

Ribs. 

Shoulder. 


Spine: 

Cervical. 

Dorsal. 

Lumbar. 

Sacrum  and  coccyx. 
Thigh. 
Wrist  and  hand. 


Each  plate  should  have  a  label,  with  the  name  of  the  patient,  the  date,  the 
name  of  the  physician  who  ordered  the  plate,  the  anatomic  region  taken,  and  a 
number,  which  number  must  be  carried  through  the  £-ray  index  and  made  to  indi- 
cate the  size  of  the  plate  by  a  decimal  point  or  otherwise,  so  that  it  can  be  found 
easily  on  the  shelves.    For  instance: 

Hospital  X-ray  Department 

Date 

Name 

Address 

Doctor 

Diagnosis 


In  some  of  the  courts  of  the  country  it  has  been  decided  not  to  accept  rc-ray 
pictures  at  all,  but  in  some  courts  z-ray  plates  are  accepted  when  the  plates  can  be 
definitely  identified  with  the  patient  at  issue  in  the  legal  proceeding.  In  order  to 
meet  this  requirement,  some  institutions  have  adopted  a  process  of  metallic  ink 
writing,  that  is,  they  write  the  name  of  the  patient  and  the  date  in  a  special  chemical 
ink  upon  a  small  piece  of  paper,  and  this  paper  is  pasted  on  the  envelope  in  which 
the  plate  is  concealed.    When  the  picture  of  the  patient  is  taken,  the  name  and 


PATIENTS'    RECORDS    .VXD    RECORD    KEEPING  175 

date,  as  written  on  the  scrap  of  paper,  appear  as  a  part  of  the  picture,  and  in  some 
courts  at  least  this  identification  has  been  accepted  as  valid. 

Perhaps  the  best  method  of  preserving  identification  of  a  plate  is  by  the  fol- 
lowing process:  A  piece  of  paper,  say,  3  inches  long  and  1  inch  wide  is  glued  with 
label  glue.  A  piece  of  tin-foil  2  inches  long  and  1  inch  wide  is  pasted  on  this  in  the 
middle,  so  that  the  glued  paster  projects  §  inch  at  each  end.  A  machine  that 
can  be  easily  purchased  on  the  market  is  used  to  stamp  out  the  patient's  admission 
number  in  the  hospital  and  the  date.  This  date  stamp,  instead  of  having  rubber 
numbers,  has  steel  figures  in  the  shape  of  a  die.  The  operator  simply  cuts  out 
the  admission  number  of  the  patient  and  the  date,  perforating  both  the  paster 
and  the  tin-foil  which  is  glued  to  it.  This  small  sheet  is  then  fastened  to  the 
envelope  of  the  plate,  so  that  when  the  picture  is  taken  that  part  covered  by  the 
tin-foil  will  be  unaffected  by  the  x-ray,  and  the  perforated  figures  will  be  acted  upon. 
When  the  plate  is  developed  these  figures  will  show  plainly,  and  the  records  of  the 
hospital  can  be  used  to  identify  the  patient  by  the  admission  number.  Undoubt- 
edly this  device  can  be  applied  also  using  a  larger  stamp,  with  the  letters  of  the 
alphabet  in  place  of  figures,  and  the  patient's  name  can  be  spelled  out  or  the  ini- 
tials can  be  given.  This  form  of  identification  works  satisfactorily  in  the  Michael 
Reese  Hospital.  The  radiologist's  signature  can  be  written  in  common  ink  on  the 
plate  as  his  own  personal  mark,  and  merely  to  indicate  to  inquirers  who  did  the 
work.    This  signature  is  not  necessary  to  identification  of  the  plate,  however. 

The  interpretation  of  x-ray  plates  is  complicated  and  quite  a  technical  matter, 
and  skill  in  their  interpretation  only  follows  great  experience  and  long  study.  In 
most  modern  institutions  the  x-ray  plates  are  kept  in  the  neighborhood  of  a 
shadow-box,  so  that  if  a  surgeon  has  an  interesting  kidney  picture  that  he  wants  to 
study,  and  if  the  plate  of  the  case  at  issue  seems  to  present  some  new  detail  with 
which  he  is  unfamiliar,  it  is  an  instructive  and  valuable  thing  for  him  to  be  able  to 
sit  down  before  a  shadow-box  with  a  large  number  of  other  kidney  plates  for  com- 
parative study,  and  so  with  all  of  the  other  localities  of  the  body  comparisons  are 
of  great  advantage.  It  is  a  valuable  acquisition  to  any  institution  to  have  on  hand 
a  great  number  of  shoulder-joint  plates,  a  great  number  of  kidney  plates,  a  great 
number  of  frontal  sinus  plates,  and  so  through  other  anatomic  regions  of  the  body, 
as  recognized  in  x-ray  photography. 

Who  Shall  Have  Access  to  .r-Ray  Plates? — Very  frequently  patients  who  have 
had  fractures,  the  results  in  which  have  not  been  quite  satisfactory,  will  want  to 
consult  their  x-ray  plates  at  the  institution,  sometimes  with  a  view  to  legal  action 
against  the  physician;  sometimes  patients  who  have  had  an  x-ray  picture  taken  at 
the  instance  of  one  physician  may  want  possession  of  the  plate  with  a  view  to  con- 
sul! a  second  physician  about  the  case;  sometimes  a  patient  may  have  placed  him- 
self in  the  hands  of  a  second  physician  who  will  want  to  see  the  x-ray  plate  taken 
on  the  order  of  a  physician  who  had  previously  treated  the  case,  and  in  any  of  these 
events  the  situation  of  the  hospital  is  rather  embarrassing.  Must  institutions  take 
the  ground  that  the  x-ray  plate  is  the  property  of  the  institution,  and  that  the 
patient  has  paid  not  for  the  plate  itself,  but  for  the  information  it  contains  for  the 
use  of  his  physician;  and  in  some  institutions  a  print  of  the  X-ray  plate  is  offered 
as  a  substitute  for  the  plate  itself,  the  institution  insisting  upon  retaining  possession 
of  the  plate  as  a  part  of  its  records,  and,  naturally,  for  the  purposes  of  the  literature. 
just  in  the  same  way  that  the  institution  would  allow  the  patient  to  have  a  copy 
of  a  record  of  his  case,  but  would  refuse  to  turn  over  to  him  the  original  record  itself. 
This  contention  is  not  very  well  received  by  people  who  have  paid  a  large  price  for 
an  x-ray  plate,  but  nevertheless  it  is  maintained  in  some  institutions,  although 


476  OPERATION   OF   THE   HOSPITAL 

it  very  often  happens  that  a  photographic  print  of  a  plate  is  not  a  very  serviceable 
substitute. 

In  the  dilemma  as  to  the  right  of  the  various  contesting  interests  to  the  pos- 
session of  the  plate  or  a  print  of  it,  we  may  fairly  assume  the  same  attitude  as  we 
did  in  the  case  of  the  record  of  the  patient.  The  patient  himself  ought  to  have 
access  to  his  a>ray  plate  and  whatever  information  it  contains,  and  it  goes  without 
saying  that  the  sacredness  of  the  relation  between  the  patient  and  the  hospital 
ought  to  inhibit  the  use  of  that  plate  by  any  one  at  variance  with  the  patient's 
interests.  In  other  words,  it  would  seem  to  be  a  fairly  safe  course  to  refuse  the 
picture  or  a  print  of  it  or  any  information  contained  in  it  to  any  one  except  the 
patient  himself,  or  some  one  to  whom  the  patient  has  given  a  written  order. 


SOCIAL  SERVICE  AND  OUTPATIENT  WORK 

Organized  Charities. — Charity  is  no  longer  merely  an  impulse  of  the  individual 
human  heart,  but,  like  everything  else  in  this  modern  day,  it  has  reached  an  era 
of  organization.  There  are  great  possibilities  of  efficiency  in  charity,  and,  with- 
out question,  it  is  wiser  than  it  used  to  be.  It  has  for  its  basic  principle  a  help- 
fulness that  helps  others  to  help  themselves.  Charity  is  an  uplifting  force  in 
principle;  it  undertakes  to  create  conditions  about  its  object  that  will  make  him 
self-supporting  and  independent.  While  it  feeds  his  stomach  in  an  emergency, 
it  finds  him  profitable  employment  so  that  he  may  buy  his  own  food.  Thus  we 
have  to-day  great  systems  of  organized  charity  in  the  large  centers  of  population 
divided  up  into  numerous  branches,  each  one  assigned  to  the  performance  of 
some  special  service  of  a  helpful  kind. 

There  are  several  very  definite  classes  of  dependents  in  every  community. 
The  largest  of  these,  of  course,  is  composed  of  children  made  public  charges  by 
reason  of  somebody's  else  fault  or  misfortune,  and  the  disability  of  this  child 
class  continues  until  the  individual  reaches  the  age  at  which  society  expects  its 
members  to  earn  their  way. 

Unwisdom  on  the  part  of  society  in  its  attitude  of  helpfulness  toward  this 
dependent  child  class  is  the  chief  agency  in  the  creation  of  the  next  most  con- 
spicuous class  of  dependents,  composed  of  the  children  of  this  first  class  after  they 
themselves  are  grown  up  and  married.  Not  having  been  wisely  brought  to  matur- 
ity, they  finally  reach  that  stage  of  life  wholly  incapable  of  mastering  its  demands. 
They  marry  early,  on  a  small  income  from  menial  labor,  bring  into  the  world  a 
race  of  weaklings  and  degenerates,  who  eventually  find  their  way  into  the  publicly 
supported  poorhouses,  insane  asylums,  homes  for  the  crippled  and  mentally  de- 
ficient, or,  worse  still,  into  the  prisons  and  workhouses  of  the  land. 

Another  class  of  dependents  is  composed  of  adults  of  both  sexes  rendered 
incapable  of  helping  themselves  by  reason  of  sickness,  either  their  own  or  some- 
body's else. 

A  fourth  class  is  composed  of  adults  of  both  sexes  who  have  been  improvident 
(hiring  prosperity  and  whose  "rainy  day"  has  found  them  unprepared. 

Let  us  briefly  analyze  the  details  of  these  classes  for  the  purpose  of  aiding  our 
judgment  as  to  the  origin  of  helplessness  and  poverty,  and  to  help  form  our  judg- 
ment as  to  how  we  shall  do  our  part  toward  finding  a  remedy. 

We  need  not  dwell  on  the  origin  of  child  helplessness.  The  reasons  are  ob- 
vious. The  fault  or  misfortune  lies  beyond  the  child,  in  the  parent,  but  we  must 
recognize  the  needs  of  the  helpless  child.  It  must  be  housed,  clothed,  fed  during 
health  and  sickness;  it  must  be  nursed  and  given  medical  attention  when  ill; 
and  when  it  has  arrived  at  a  proper  age  its  education  must  be  attended  to,  if  not 
because  of  our  unselfish  humanitarianism,  then  in  the  defense  of  and  for  the  pro- 
tection of  society  in  general,  which  means  the  moral  health  of  the  community  and 
the  individual. 

Let  us  pass  now  to  those  who  have  been  rendered  incapable  of  making  a  living 
because  of  illness,  either  their  own  or  others  who  are  dependent  on  them.  In  a 
survey  of  this  class  we  may  assume  that  the  disability  is  more  or  less  temporary 


478  OPERATION    OF   THE   HOSPITAL 

in  character,  and,  therefore,  any  aid  that  may  be  required  is  not  likely  to  be  con- 
tinuous. In  the  event  that  the  illness  occasioning  the  dependency  transpires  to  be 
of  an  incurable  character,  then  we  have  an  added  problem,  not  in  the  direction  of 
helpfulness,  but  in  the  length  of  time  for  which  it  will  be  required;  that  is,  we  may 
have  to  take  care  of  the  sick  individual  for  life. 

The  next  is  by  far  the  most  perplexing  and  important  class  of  dependents; 
that  is,  those  who  by  improvidence  during  prosperity  have  rendered  themselves 
helpless  during  adversity.  This  is  a  most  formidable  problem  for  mastery;  for- 
midable because  the  objects  of  anxiety  and  interest  and  intercession  are  often- 
times unwilling  participants  in  any  remedial  activities  in  their  behalf.  As  a  rule 
the  members  of  this  class  have  been  the  victims  of  ignorance,  intemperance,  or 
idleness. 

We  take  no  cognizance  just  here  of  another  class  of  our  society,  not  in  any 
way  reprehensible  or  blameful  for  their  condition,  that  is,  former  inhabitants  of 
older  countries  who  have  been  driven  from  their  fatherland  by  oppression  at  home, 
or  whose  inherent  ambition  has  led  them  to  seek  freer  and  more  prosperous  and 
happier  lives  in  a  newer  and  more  promising  environment.  This  class  of  tem- 
porary dependents  should  be  placed  upon  a  far  different  plane  than  the  other 
classes  upon  which  we  have  touched,  and  we  shall,  later  on,  elaborate  upon  means 
for  helping  this  class  of  dependents  to  become  independent. 

Let  us  revert  now  to  those  who  have  been  made  dependent  by  ignorance,  in- 
temperance, or  idleness;  and  by  ignorance  we  mean  an  absence  of  that  judgment 
and  business  acumen  that  permits  most  normal  citizens  to  hold  their  own  at  least 
to  the  extent  of  a  living  in  the  ordinary  competition  of  life.  This  is  neither  the 
time  nor  place  to  dilate  upon  the  philosophies  of  life  that  endow  one  individual  with 
the  gifts  that  make  for  worldly  prosperity  and  that  withhold  those  faculties  or 
inheritances  from  another  individual.  If  we  were  to  become  involved  in  a  dis- 
cussion upon  this  line,  we  should  have  to  invade  the  whole  realm  of  society,  and  if 
we  undertook  to  prescribe  a  remedy,  going  back  to  the  origin  of  this  state  of  things, 
we  should  have  to  recommend  a  complete  revolution  in  our  whole  social  fabric, 
at  the  end  of  which  men  and  women  and  babes  from  their  birth  must  live  not  in  the 
light  of  human  passions  and  human  frailties,  but  with  mathematic  regularity  along 
hard-and-fast  lines  fixed  by  laws  that  an  enlightened  citizenship  would  not  en- 
dorse. 

What  we  are  concerned  with  now  is  a  set  of  morals  and  methods  by  which 
social  dependents  may  be  lifted  from  their  class  into  the  higher  levels  of  society; 
and  in  a  last  analysis  this  is  the  very  crux  of  the  problem  which  we  indifferently 
call  charity  and  philanthropy.  It  is  hardly  charity  and  it  is  certainly  not  philan- 
thropy, which  means  love  of  one's  fellowman,  to  feed  a  fellow  human  being  just  to 
tide  him  over  from  one  hour  of  misery  to  another.  It  would  be  charity  to  give  him 
a  dose  of  poison  to  end  his  sufferings  in  such  a  case,  or  throw  him  into  the  sea  with  a 
millstone  about  his  neck.  What  we  must  do  is  to  feed  him  first,  because  that  is 
his  immediate  need,  and  then  to  help  him,  by  reason  of  our  greater  strength  and 
better  position,  to  a  situation  in  which  he  can  be  enabled  to  help  himself.  If 
poorhouses  and  almshouses  must  be  maintained,  it  must  be  done  in  the  interest 
of  the  incurably  sick  or  the  helplessly  aged.  And  such  institutions  as  these  need 
give  us  no  worry  nor  cost  an  anxious  hour.  It  is  the  duty  of  society,  which  society 
recognizes,  to  take  care  of  its  derelicts  until  they  have  passed  beyond  need  of  help. 
But  the  other  problem,  the  one  of  helping  the  weak  to  tide  over  the  bad  places 
in  the  pathway  of  life  until  the  going  is  better  or  until  they  are  strong  enough  to  go 
alone,  that  is,  the  one  that  has  brought  into  existence  innumerable  ideas,  methods 


SOCIAL   SERVICE    AND    OUTPATIENT    WORK  479 

without  number,  and  that  has  diverted  millions  in  money  in  more  or  less  inefficient 
and  fruitless  attempts  to  find  a  cure  for  misery,  poverty,  and  despair. 

And  so  in  various  parts  of  the  world  and  from  time  immemorial  countries  and 
communities  and  individuals  have  sought  by  one  method  or  another  to  create  a 
human  machinery  for  help  that  shall  become  self-help,  and  to-day  we  are  coming 
nearer  to  a  solution  of  the  great  world-wide  problems  involved  in  what  we  have 
come  to  call,  in  this  country  at  least,  social  service. 

The  Dispensary. — Almost  since  the  dawn  of  history  there  have  been  masters, 
and  slaves,  not  called  such  always  perhaps,  but  in  reality  such  nevertheless,  and 
since  these  slaves  were  considered  as  property  and  chattels,  their  health  and  per- 
sonal welfare  were  of  interest  to  the  masters.  If  the  slave  was  sick  he  could  not 
work,  hence  the  master  employed  a  physician  to  heal  him,  not  out  of  any  altruistic 
motive,  but  for  a  mercenary  end.  Later  on  there  were  military  lords  and  their 
retainers,  which  mustered  upon  occasion  into  legions  for  military  service.  If  a 
soldier  was  wounded  he  could  no  longer  fight,  hence  a  military  surgeon  and  physi- 
cian was  kept  with  the  troops  to  maintain  the  fighting  men  in  trim,  and  at  the 
end  of  the  wars,  when  the  soldiers  returned  home,  the  practice  was  continued; 
the  master  provided  a  physician  for  his  vassals,  and  the  soldiers  and  their  fami- 
lies visited  the  moated  castle  for  medicines  and  surgical  attention. 

The  religious  orders  at  an  early  day  took  upon  themselves  the  work  of  min- 
istering to  the  sick;  it  was  at  a  time  when  the  priests  of  all  the  creeds  were  the 
only  educated  people,  and  naturally  a  part  of  their  education  involved  the  healing 
of  disease,  sometimes  by  necromacy  and  charlatanism,  but  nevertheless  with 
greater  efficiency  than  could  have  been  clone  by  any  other  class.  These  priests 
were  charged  by  the  princes  and  overlords  with  the  duty  of  keeping  the  soldiers 
and  their  families  in  good  health.  From  this  beginning  grew  up  the  monasteries 
and  the  hospices  of  Europe.  After  a  time  there  came  the  inevitable  abuses  that 
thrive  on  privilege,  and  society  took  over  the  care  of  the  sick  by  the  creation  of  dis- 
pensaries. These  dispensaries  were  merely  centers  to  which  the  sick  poor  might 
drag  themselves  for  medicines  and  ministrations  in  the  way  of  minor  surgery. 

In  the  next  stage  of  the  evolution  we  find  the  doctor  becoming  interested  in  his 
patient,  not  yet  for  love  of  his  fellowman,  perhaps,  but  because  of  an  ambition  to 
excel  in  his  profession,  and  we  find  him  gravely  curious  to  know  whether  his  patient 
was  taking  his  medicine  and  doing  at  home  whatever  the  prescription  called  for; 
and  the  doctor  sent  some  one  there  to  see.  The  messenger  perhaps  reported  unsani- 
tary surroundings,  lack  of  comforts,  and  even  the  necessities  of  life,  and  so  the  doc- 
tor interested  himself  among  his  rich  friends  to  see  that  these  necessities  and 
comforts  were  provided. 

Thus,  by  easy  stages,  we  find  the  dispensary  doctor  invading  the  home  of  sick- 
ness and  misery  and  distress,  and  attempting  in  the  best  way  he  knew  how  to  extend 
a  helping  hand. 

Then  the  poor  began  to  frequent  the  dispensary,  not  for  themselves,  but  to 
report  some  bad  condition  of  a  neighbor  or  an  illness  in  a  neighbor's  family,  and 
the  doctor's  assistants  were  sent  to  see  what  could  and  should  be  done.  With  the 
dispensary  as  a  nucleus  the  good  that  was  in  the  human  heart  began  to  shine  out 
into  the  homes  of  the  poor  and  sick,  and  so  every  ill  to  which  humanity  was  heir 
came  for  its  turn  of  the  helping  hand,  with  the  doctor  always  in  the  forefront, 
the  inspiration  and  the  instrument  for  doing  good  anil  lightening  the  loads  of  the 
burdenbearers  of  society. 

Social  Service  Broadens  Out. — Then  came  the  era  of  organization.  Society  was 
no  longer  a  heterogeneous  mass  of  individuals  striving  for  individual  success  and 


480  OPERATION   OF   THE    HOSPITAL 

preferment  and  prosperity,  but  collective  humanity  in  its  own  interest  banded  itself 
together  and  became  an  organization  with  wheels  within  wheels,  a  machine  for 
doing  society's  work  more  efficiently  than  it  could  be  done  by  individual  effort;  and 
this  spirit  of  organization  was  not  long  in  expressing  itself  also  in  the  work  of  charity 
and  in  the  various  fields  of  philanthropy.  Hospitals,  orphan  asylums,  homes  for 
the  aged  and  incurable  were  organized,  and  the  work  became  specialized.  Small 
groups  of  society  bent  their  efforts  toward  a  single  purpose,  one  group  taking  one 
special  need  of  the  community  and  another  group  another  need.  And  so  after 
awhile  there  came  specialization  in  charity  and  philanthropy,  just  as  to-day  we 
have  specilization  in  everything,  the  sciences,  arts,  and  industries.  And  these 
various  groupings  of  charity  and  philanthropy  are  now  organized  into  what  we  call 
social  service,  or  into  what  the  general  hospitals  call  outpatient  work. 

Let  us  take,  then,  one  concrete  organization  for  example,  with  ramifications 
into  every  avenue  of  human  need.  We  have,  first,  the  dispensary,  which  has  be- 
come not  so  much  a  place  from  which  to  dispense  medicine,  as  a  bureau  of  informa- 
tion by  which  a  central  organization  is  made  acquainted  with  the  need  of  the 
applicant. 

Then  there  is  the  visiting  physician  who  must  go  to  the  home  to  find  out  what 
is  most  wanted,  and  the  visiting  nurse  who  accompanies  or  follows  him  to  carry 
out  his  orders. 

Next  we  find  the  emergency  relief  bureau,  whose  duty  it  is  to  find  provisions 
and  fuel,  clothing  and  bedding,  and  to  improve  the  housing  of  the  destitute  family; 
and  thus  we  have  all  immediate  needs  provided  for,  and  then  the  avenue  broadens: 

The  hospital  for  whoever  may  be  ill. 

The  orphanage  if  the  family  should  be  broken  up  by  death,  or,  in  its  stead, 

The  home  of  the  friendless,  whose  rules  will  permit  the  admission  of  the  mother 
of  the  family,  perhaps,  and  her  small  children  until  permanent  arrangements  can 
be  made  for  them. 

Perhaps  there  is  a  tiny  babe  whose  mother  has  died  in  giving  it  birth.  The  relief 
bureau  will  bury  the  dead,  but  there  must  be  a 

Home-finding  bureau  to  dispose  of  and  watch  over  the  child.  But  perhaps  it  is 
not  illness  that  the  visitors  find,  but  a  mother  and  child  who  have  been  abandoned 
by  a  worthless  father.  Again,  the  relief  bureau  provides  for  the  emergency  and 
calls  in  a 

Legal  aid  bureau,  which  must  find  the  father  and  compel  him  to  return  to  his 
abandoned  home  and  to  care  for  his  wife  and  child. 

But  perhaps  the  father's  excuse  is  that  he  has  been  unable  to  find  employment, 
and  so  purposely  refrained  from  returning  home,  in  the  hope  that  the  charitably 
inclined  would  have  pity  upon  his  wife  and  child  and  would  give  them  the  care 
that  perhaps  would  have  been  withheld  were  it  known  there  was  a  father  to  pro- 
vide for  them.     And  so  we  must  have  an  employment  bureau. 

But  it  may  not  have  been  any  of  the  above  ills  that  have  overtaken  the  family; 
the  father  may  have  been  killed  or  seriously  injured  while  at  work  or  by  some 
public  service  corporation.  Such  a  helpless  family  would  prove  an  easy  victim  for 
a  wealthy  corporation  or  employer,  and  so  this  same  organization  must  step  to  the 
front  through  the  medium  of  its  legal  aid  and  compel  payment,  if  not  sufficient  to 
atone  for  the  loss  of  the  husband  and  father,  at  least  in  a  sufficient  amount  to  help 
take  care  of  the  widow  and  orphan. 

Again,  the  misfortune  may  be  found  in  the  form  of  an  erring  girl,  who  has  been 
overtaken  by  the  misfortune  common  to  her  class,  and  so  a  rescue  bureau  for  young 
girls  is  a  real  need,  where  the  girl  may  be  cloistered  in  some  quiet  retreat  up  to  her 


SOCIAL   SERVICE    AND   OUTPATIENT    WORK  481 

maternity.  Then  the  hospital  comes  again  and  the  home-finding  society,  and  per- 
haps the  relief  bureau  for  the  emergency  of  her  return  to  her  home,  and  the  employ- 
ment bureau  to  find  her  work. 

But  perhaps  it  is  a  sick  babe  or  small  child  that  the  visiting  doctor  and  nurse 
are  called  to  see,  and  an  infant  diet  is  urgently  demanded.  In  these  days  of  milk 
trusts,  and  at  a  time  when  the  so-called  pure  food  laws  throughout  the  land  permit 
the  sale  of  the  most  vilely  adulterated  human  foods  that  the  mind  can  conceive,  it 
would  be  necessary  to  go  far  for  milk  that  a  sick  child  can  get  well  upon,  and  in 
many  communities,  thanks  to  the  glorious  initiative  of  Nathan  Straus,  there  are 
milk  commissions  and  milk  depots  in  nearly  all  populous  communities  of  this 
country  where  the  poor  can  have  pure  milk  at  cost  or  free. 

Again,  it  may  be  none  of  these  misfortunes  that  the  doctor  may  find.  The 
home  of  poverty  may  be  burned  down  or  lost  through  debt,  or  the  peddler's  horse 
may  be  dead,  or  the  peddler's  pack  may  be  lost.  If  there  were  another  horse,  or 
another  pack,  or  a  little  furniture  for  a  new  home,  the  family  might  rally  again,  but 
there  is  no  money;  and  so  generous  communities  have  organized  loan  associations 
from  which  unfortunates  may  borrow  the  few  dollars  they  need  for  temporary  tiding 
over,  without  interest  or,  at  least,  without  usury. 

And  so  on  ad  infinitum  society  has  specialized  in  its  charities  and  in  its  philan- 
thropies, and  the  common  aim  is  ever  progressing  toward  a  goal  at  which  the  needy 
can  get  help  without  encouragement  to  become  objects  of  permanent  charity. 

Outpatient  Hospital  Service. — A  great  many  general  hospitals,  especially  those 
well  endowed,  undertake  more  or  less  elaborate  service  to  patients  not  admitted 
to  the  institution.  This  is  a  species  of  dispensary  service  and  is  organized  and 
conducted  to  provide  for  several  classes  of  people  who  are  physically  ill,  yet  not 
sufficiently  incapacitated  to  be  put  to  bed  in  the  institution.  First  among  these 
classes  we  have  the  convalescent;  the  busy  charity  hospital  is  maintained  at  so 
great  an  expense  in  this  modern  day  that  it  cannot  afford  to  keep  convalescents 
until  they  are  strong  enough  to  go  to  work,  and  they  will  continue  to  need  medi- 
cal care  or  at  least  the  watchfulness  of  a  nurse  at  their  homes  throughout  their 
convalescence,  and  the  hospital  can  provide  this  attention  and  does  so  in  many 
instances  through  a  visiting  nurse  bureau,  and  even  if  regarded  purely  from  a 
mercenary  standpoint  such  a  service  is  a  paying  one,  because  patients  can  be 
sent  home  much  sooner  if  it  is  definitely  understood  by  attending  physicians  that 
they  will  be  followed  to  their  homes  and  watched,  nursed,  and  cared  for. 

Surgical  cases  are  sometimes  long  drawn  out,  especially  where  drains  have  been 
necessary,  or  in  cases  of  tubercular  joints  or  chronic  inflammatory  affections  of  the 
internal  organs.  If  these  patients  can  be  returned  to  the  hospital  or  to  the  dis- 
pensary for  dressing,  or  if  they  can  be  visited  at  their  homes  by  a  physician  provided 
for  the  purpose,  or  by  a  visiting  nurse,  the  patients  can  be  sent  home  far  earlier. 

If  the  institution  is  a  maternity  hospital  or  has  a  lying-in  department,  outpatient 
work  is  of  vast  importance  and  will  save  the  institution  substantial  sums  of  money 
and  greatly  extend  its  usefulness.  It  will  oftentimes  be  imperative  to  admit  to  the 
hospital  pregnant  women  who  are  sick  long  before  their  time,  women  who  have  hearl 
lesions,  for  instance,  or  who  have  nephritis,  either  of  which  may  have  been  vastly 
exaggerated  by  their  pregnancy,  and  are  liable  to  meet  with  serious  consequences 
unless  carefully  watched.  Women  with  deformities  of  one  sort  or  another,  such 
as  contracted  pelvis,  are  likely  to  meet  with  serious  trouble  unless  carefully  watched 
during  the  whole  period  of  their  pregnancy.  Women  whose  pregnancy  is  com- 
plicated with  a  tumor  of  some  sort  are  liable  to  bleed  alarmingly  and  to  meet  with 
irretrievable  disaster  unless  they  are  under  the  eye  of  a  medical  attendant  or  intelli- 


482  OPERATION    OF   THE    HOSPITAL 

gent  nurse.  And  so  with  women  who  have  frequently  aborted  or  who  are  known 
as  "bleeders."  For  almost  any  of  these  cases  an  actively  and  intelligently  con- 
ducted outpatient  service  will  save  the  hospital  the  necessity  of  providing  a  bed 
and  board  for  them. 

Parole  of  Children. — In  the  children's  department  or  in  a  children's  hospital 
an  outpatient  service  is  quite  as  important.  Many  sick  children,  especially  those 
who  have  been  badly  nursed  or  neglected,  begin  with  gastro-intestinal  disturb- 
ances, pneumonias,  typhoid  fevers,  or  rheumatism,  and  finally  develop  bad  hearts, 
kidneys,  or  lungs.  Many  of  these  children  recover  after  awhile  if  they  have 
proper  care,  but  it  takes  months  and  sometimes  years  for  them  to  get  well,  and  they 
have  almost  no  chance  ever  to  get  well  unless  the  parents  at  home  have  the  guid- 
ance of  some  intelligent  person  who  can  direct  the  feeding  and  other  care  of  the 
child.  No  institution  can  afford  to  keep  these  children  through  all  the  necessary 
months  or  years,  nor  is  it  desirable  to  do  so.  An  outpatient  service  could  do  this 
work  admirably,  especially  if  there  is  a  reasonable  fund  available  out  of  which  to 
provide  good  milk  and  eggs,  and  some  of  the  commoner  yet  wholesome  articles  of 
child  diet.  Oftentimes  these  children  can  be  returned  to  the  hospital  frequently, 
and  in  some  institutions  there  is  a  parole  system  in  practice.  In  the  working  out 
of  this  system  the  parents  of  the  child  are  given  a  return  card  which  provides  that 
the  child  shall  be  returned  to  the  hospital  for  examination  on  stated  days,  according 
to  the  necessities  of  the  case.  The  wording  of  this  card  is  of  some  moment,  and, 
therefore,  it  is  reproduced  here: 

MICHAEL  REESE   HOSPITAL 
Child's  Return  Card 

Name  of  Child Admission  No 

Date  of  Admission Date  of  Discharge 

Diagnosis Name  of  Physician 

Parents  Read  This.    You  are  expected  to  bring to  the  Michael  Reese 

Hospital  every  Saturday  morning  at  9  o'clock  to  have  her  examined  by  Doctor 

Signed Supt. 

A  similar  card,  worded  a  little  differently,  is  employed  in  the  maternity  depart- 
ment, and  in  the  working  out  of  the  system  the  mother  is  obligated  to  return  to  the 
hospital  at  stated  intervals  to  be  examined,  and  both  she  and  her  infant  are  thus 
watched .  and  guided  beyond  the  critical  stages  of  nursing  and  infancy.  The 
mothers  of  both  these  classes  of  children  seem  to  take  great  interest  in  this  privi- 
lege, and  are  grateful  for  the  constant  watchfulness  of  the  institution  over  their 
little  ones,  and  it  transpires  that  there  are  few  women  who  fail  or  refuse  to  return 
their  children  at  the  times  indicated. 

This  parole  system  is  an  excellent  procedure  also  in  institutions  that  are  affili- 
ated with  or  a  part  of  medical  schools,  because  the  parole  cards  can  be  made  to 
call  for  the  return  of  certain  classes  of  children  on  clinic  days,  and  thus,  for  in- 
stance, a  great  number  of  heart  cases  or  kidney  cases  can  be  assembled  when  the 
class  is  studying  those  particular  diseases  of  childhood. 

Another  class  of  patients  that  is  worthy  of  a  systematic  outpatient  service  is 
those  suffering  from  chronic  disorders,  as,  for  instance,  tuberculosis,  either  pulmo- 
nary or  of  some  other  part  of  the  body.     These  patients  are  not  good  hospital  cases 


SOCIAL   SERVICE   AND    OUTPATIENT   WORK  483 

and  arc  usually  not  admissable  in  the  wards  of  general  hospitals,  and  until  Bociety 
is  better  organized  to  rare  for  tuberculous  patients  in  special  institutions  an  out- 
patient service  is  tin- next  liest  thing.  It  is  not  profitable  to  the  patient  to  have  him 
returned  to  the  hospital  for  frequent  examinations,  and  a  visiting  physician  or 
an  intelligent  visiting  nurse  in  the  home  will  give  a  better  service.  Usually  the 
great  trouble  with  tuberculous  patients  is  that  they  are  so  optimistic  that  they  refuse 
to  realize  the  gravity  of  their  condition,  and  they  go  back  to  their  homes  and  live 
just  as  though  they  were  well.  They  fail  to  care  for  themselves  properly,  ignore  t  he 
necessities  of  diet  and  fresh  air;  and  they  constantly  expose  other  members  of  their 
families  to  infection  because  they  refuse  to  believe  they  are  dangerous.  The 
visiting  physician  or  nurse  will  not  fail  to  observe  existing  conditions  in  the  home, 
and  in  most  cases  can  have  an  immensely  important  effect  in  regulating  the  lives 
and  habits  of  these  patients  and  in  protecting  other  members  of  the  family. 

There  is  another  outpatient  service  that  is  perhaps  quite  as  important  as  any 
of  the  foregoing,  and  that  especially  concerns  those  institutions  whose  problem 
involves  the  care  of  a  definite  class  in  the  community,  as,  for  instance,  the  sick 
poor  of  a  settlement  of  foreigners.  These  people  often  are  huddled  together  like 
burrowing  animals,  in  ill-ventilated,  poorly  lighted,  unsanitary  hovels,  garrets,  or 
basements.  If  one  of  their  number  falls  sick,  the  others  will  crowd  about  him,  with- 
holding from  him  nature's  aids  to  health,  to  say  nothing  of  their  neglect  or  inability 
to  provide  for  him  a  doctor.  A  physician  provided  by  the  community  or  a  visiting 
nurse  with  her  trained  mind,  hand,  and  eye  may  mean  health  to  the  sufferer  and 
vastly  unproved  conditions  to  the  balance  of  the  family.  Oftentimes  sick  people 
under  these  conditions  apply  for  admission  to  the  hospital  through  their  friends 
or  relatives. 

The  patient  is  sick  at  home,  and  an  ambulance  will  be  needed  for  conveyance  to 
the  hospital.  Oftentimes  it  is  an  incurable  disease  from  which  the  patient  suffers, 
one  not  desirable  in  the  general  hospital,  or  the  patient  may  be  merely  afflicted  with 
old  age,  another  undesirable  disease  for  the  wards  of  a  general  hospital;  or  it  may  be 
a  communicable  disease  of  some  sort  that  should  go  to  some  particular  institution 
organized  for  the  care  of  just  such  cases.  In  other  words,  there  are  great  numbers 
of  sick  people  at  home  in  bed  who  apply  for  admission  to  the  general  hospital  who 
do  not  belong  there,  and  if  there  can  be  a  visiting  physician  or  even  an  intelligent 
nurse  to  visit  the  home  and  sec  the  patient,  it  will  save  the  patient  great  distress  and 
suffering  in  transportation,  and  frequently  will  save  the  hospital  from  the  burden 
of  a  patient  thai  does  not  belong  there,  as  well  as  the  service  of  the  ambulance  or 
other  means  of  transportation. 


BUSINESS  MANAGEMENT 

THE  OFFICE 

The  business  office  of  a  general  hospital  and  of,  indeed,  any  institution  intended 
for  the  care  of  the  sick  or  dependent  is  a  clearing-house  for  the  transaction  of  all 
of  the  business  appertaining  to  the  admission,  care,  and  discharge  of  the  patient. 
So  that,  in  contemplation  of  the  business  office  of  an  institution,  we  may  as  well 
begin  at  the  actual  beginning — the  admission  of  the  patient  to  the  institution. 

It  makes  no  difference  whether  the  patient  is  brought  to  the  institution  by  the 
city  authorities,  or  the  police,  or  in  an  ambulance  from  his  own  home,  or  walks  in, 
or  is  driven  up  in  his  own  automobile.  The  technic  of  his  admission  is  practically 
the  same,  with  a  few  unimportant  differences. 

Let  us  consider,  first,  the  pay  patient,  as  we  are  pleased  to  call  the  man  or 
woman  or  child  who  proposes  to  pay  his  or  her  way  in  the  institution.  Such  a 
patient  usually  is  sent  by  some  physician  who  has  the  right  to  treat  patients  in  the 
hospital.  A  question  frequently  asked  in  this  connection  is  whether  a  private 
patient  sent  in  by  a  physician  should  be  subjected  to  a  physical  examination  at  the 
hands  of  the  hospital  admission  department.  The  answer  would  seem  to  be  both 
Yes  and  No.  If  the  physician  is  a  member  of  the  staff,  and  is  wholly  responsible 
for  his  actions  and  can  be  relied  on,  and  is  a  man  who  knows  definitely  the  policy 
of  the  institution  as  to  the  character  of  patients  which  it  is  willing  to  receive,  it 
would  seem  humiliating  and  unnecessary  to  subject  his  private  patient  to  examina- 
tion at  the  hands  of  some  young,  inexperienced  medical  man,  the  implication  being 
that  the  hospital  is  in  doubt  as  to  the  admissibility  of  the  patient,  and,  hence,  of 
the  honesty  of  purpose  of  the  physician  who  has  sent  him  in;  and  attending  physi- 
cians, under  such  circumstances,  will  and  have  a  right  to  resent  an  admission 
examination  of  their  patient. 

But  there  is  also  the  other  side  of  the  question.  The  physician  may  be  a  high- 
class  man,  one  held  in  the  highest  esteem  in  the  community,  but  he  may  not  be 
directly  connected  with  the  institution,  and  he  may  not  know,  for  instance,  that 
the  hospital  does  not  take  infectious  diseases  or  incurable  diseases,  and  it  would 
seem  that  under  such  circumstances  it  would  be  entirely  proper  for  the  hospital 
to  exercise  at  least  that  amount  of  surveillance  necesary  to  protect  itself  against 
the  admission  of  an  undesirable  patient  for  whatever  reason,  and  it  would  hardly 
seem  that  an  outside  physician,  under  such  circumstances,  could  legitimately 
complain  of  the  exercise  of  such  discretion. 

In  any  event,  the  examination  of  a  private  patient  in  the  admission  rooms  of  the 
hospital  should  never  go  beyond  the  point  of  determining  whether  the  patient  is 
one  that  the  hospital  can  properly  accept. 

Now  let  us  carry  these  pay  patients  a  step  farther  into  the  institution,  because 
the  technic  of  their  reception  is  just  a  little  different  in  one  other  detail  from  that 
of  the  free  patient.  Let  us  agree  that  this  pay  patient  is  acceptable  to  the  insti- 
tution and  that  there  is  a  room  or  bed  available,  and  that  the  admission  cards, 
which  we  shall  presently  consider,  have  been  properly  made  out,  and  the  patient 
ready  to  be  taken  upstairs.     It  is  of  almost  daily  occurrence  in  most  institutions 

484 


BUSINESS    MANAGEMENT  485 

that  patients  complain  about  ■unexpected  charges  in  their  hills.  It  is  nut  thai  they 
are  surprised  at  the  price  of  the  room,  perhaps,  or  certain  of  the  extras  that  seem 
reasonable  to  them,  but  it  so  frequently  happens  that  there  has  been  some  item 
of  expense  included  of  which  the  patient  or  his  friends  were  not  aware  and  did  not 
expect,  that  the  whole  incident  is  an  unpleasant  one  and,  it  would  seem,  quite  un- 
necessary. We  are  not  to  discuss  hospital  charges  at  this  point,  but  only  the  hos- 
pital bill,  and  that  briefly. 

If  there  must  be  extra  charges  in  addition  to  that  for  the  room  or  bed,  the 
patient,  it  would  seem,  has  a  right  to  know  what  those  charges  are.  In  the  hotels 
there  is  a  room  card  attached  to  the  inside  of  all  room  doors  on  which  is  printed 
whatever  information  it  is  necessary  for  the  guest  to  have.  This  cannot  very  well 
be  done  in  a  hospital,  because  in  many  of  the  rooms  there  is  more  than  one  patient, 
and  perhaps  there  are  different  charges  under  varying  circumstances,  and  hospital 
patients  are  not  all  on  the  same  footing,  nor  can  they  be.  So  it  would  seem,  there- 
fore, that  the  announcement  of  the  conditions  under  which  the  patient  is  in  the 
institution  ought  to  be  an  individual  affair,  and  that  each  patient  ought  to  be  given 
the  necessary  information  as  he  enters  the  hospital.  In  some  institutions  there  is 
an  admirable  practice  of  keeping  a  card  with  blank  spaces  to  be  filled  in,  and  this 
card  is  filled  in  for  each  patient  who  is  admitted,  and  is  taken  upstairs  to  the 
patient's  room  and  handed  either  to  the  patient  himself,  if  his  physical  condition 
warrants,  or  to  the  responsible  member  of  his  family  who  accompanies  him  to  the 
institution.  This  card  is  a  matter  of  a  good  deal  of  interest,  and  it  serves  its 
purpose  so  well  where  it  is  employed  that  it  is  reproduced  below : 

MICHAEL   REESE    HOSPITAL 

RULES  FOR  PRIVATE  ROOM  PATIENTS 

The  price  of  room is dollars  per  week,  payable  weekly.     Patients 

remaining  less  than  one  week  will  pay  an  additional  20  per  cent,  for  fraction  of  a  week. 

Private  patients  are  entitled  to  board,  medicine,  and  usual  nursing  without  additional  charge, 

Inn   an  additional  charge  will  be  made  in  all  surgical  eases,  amounting  to dollars, 

to  cover  part  of  the  cost  of  the  use  of  the  operating-room,  also  the  actual  cost  of  gas  (when  usedl 
at  the  rate  of  $2.00  for  each  fifteen  minutes  of  an  operation.  An  additional  charge  will  be  made 
for  rare  and  expensive  drugs,  if  specially  obtained  for  an  individual  case;  champagnes,  wines, 
and  mineral  waters  will  also  be  charged  for. 

a--Ray  pictures  and  treatment  are  extra,  the  former  for  head  or  trunk  $10.00,  arm,  leg  or 
teeth  $5.00;  fur  treatment  according  to  the  service  rendered. 

Antitoxins,  serums,  and  vaccines  $5.00  and  upward,  according  to  the  service. 

Special  house  nurses  will  be  furnished  at  Slo.00  per  week.  ( 'ii'aduate  nurses  charge  $25.00 
per  week  for  their  services,  and  the  Bospital  charges  $5.00  per  week  for  their  board. 

Patients  are  requested  not  to  bring  valuables  to  the  Hospital,  as  the  Hospital  will  not  be 
responsible  for  the  same,  unless  turned  in  at  the  office  and  a  receipt  given  therefor. 

The  Hospital  furnishes  meals  to  visiting  friends  in  the  guests'  dining  room,  when  desired, 
at  a  charge  of  50  cents  for  breakfast,  $1.00  for  dinner  and  SI. 00  for  supper. 

Patients  may  be  visited  (subject  to  the  orders  of  the  attending  physician  or  surgeon    from 

9  A.  M.  to  8  p.  M.,  but  not  more  than  two  visitors  will  be  allowed  to  remain  in  a  patient's  room  :ii 
one  time. 

Signed Superintendent. 

ADMISSION  OF  THE  FREE  PATIENT 

Every  free  patient  thai  comes  to  the  hospital  applying  for  admission  should 
pass  through  the  examining  room,  no  matter  by  whom  sent  or  under  what  circum- 
stances. If  lie  has  been  sent  from  a  dispensary  other  than  thai  of  the  institu- 
tion itself,  it  is  reasonably  certain  thai  aol  agreal  deal  of  care  or  consideration  has 

been  taken  to  guard  the  interests  of  the  bospital;  and  experience  lias  taught  US  thai 


486  OPERATION    OF    THE    HOSPITAL 

the  average  doctor,  whether  a  private  practitioner  or  employed  in  a  dispensary, 
is  too  apt  to  give  a  card  for  a  patient's  entry  to  a  hospital,  either  to  get  rid  of  the 
patient  or  out  of  pure  "good-heartedness,"  or,  as  it  has  been  sometimes  stated, 
"out  of  charity" — that  somebody  else  pays  for. 

If  the  patient  is  sent  in  by  a  member  of  the  staff,  a  busy  man  perhaps,  with  a 
large  private  practice  and  little  time  at  his  disposal  for  the  examination  and  con- 
sideration of  free  patients  elsewhere  than  in  the  hospital,  it  will  be  fairly  certain  that 
he  has  been  actuated  by  one  of  two  considerations:  either  the  patient  is  a  protege 
or  perhaps  a  servant  of  some  responsible  person  whom  he  is  pleased  to  favor,  or 
he  has  been  actuated  by  a  feeling  that  on  general  principles  the  patient  will  be 
better  off  in  the  hospital  where  he  can  get  good  attention  and  be  cleaned  up  for  a 
better  examination.  In  either  event  it  would  seem  best  to  pass  the  patient  through 
the  examining  rooms  for  the  purpose  at  least  of  a  sufficiently  definite  diagnosis  to 
determine  the  service  in  the  hospital  to  which  he  should  be  assigned. 

As  soon  as  the  applicant  is  inside  the  doors  of  the  institution  and  his  wants 
ascertained  he  should  be  handed  a  card  which  calls  for  an  examination  at  the 
hands  of  the  admission  physician.     A  very  serviceable  form  of  such  card  follows: 


ADDRESS 

SENT  BY 

DISEASE 

ADMIT  TO  SERVICE 

REASON  REFUSED 

EXAMINED  BY  DR.  DATE 


If  there  is  a  large  admission  service,  interns  or  examining  house  physicians  are 
very  often  careless  about  filling  out  this  card,  but  it  should  be  insisted  upon,  and 
especially  in  the  case  of  applicants  who  are  refused  admission,  because  it  very 
frequently  happens  that  influential  persons  are  interested  in  applicants  for  free  care 
in  a  hospital,  and  it  quite  as  frequently  happens  that  applicants  refused  admission 
because  of  the  apparent  slightness  of  their  illness  develop  soon  after  a  serious 
condition,  and  the  institution  is  more  than  likely  to  be  called  on  by  some  one  who 
has  a  right  to  ask  for  a  reason  why  the  applicant  was  rejected;  therefore  this 
examination  card  should  state  specifically  and  in  as  great  detail  as  possible  just 
what  was  found  and  why  the  patient  was  rejected.  These  cards  should  be  kept  in 
two  file  cases,  one  for  patients  actually  admitted,  to  be  kept  in  the  main  office  of 
the  hospital;  and  the  other,  the  "rejected"  cards,  may  be  kept  in  a  file  alphabetically 
arranged  in  some  private  drawer,  under  lock  and  key,  in  the  admission  room,  where 
they  can  be  consulted  at  any  time  by  those  in  charge. 


BUSINESS    MANAGEMENT 


is? 


DETAILS  OF  THE  ADMISSION 

As  soon  as  a  patient  presents  himself  in  the  business  office  of  the  institution 
for  admission,  either  with  a  card  from  the  examining  room  or  as  the  private  patient 
of  a  physician,  and  it  is  agreed  that  lie  shall  he  accepted,  the  admission  cards  are 
made  out.  There  are  two  of  these  cards,  differing  only  in  size  and  in  the  further 
particular  that  the  large  one  contains  whatever  financial  arrangement  exists  between 
the  patient  and  the  hospital,  while  all  reference  to  finance  is  omitted  from  the 
small  card.  The  large  card  is  printed  below,  and  it  would  seem  that  this  card  would 
meet  with  all  the  requirements  of  most  general  hospitals,  purely  as  a  card  of 
admission  and  for  no  other  purpose: 


"*"• 

Dele 

W.rd  or  Room 

AdmlMlon  Ho. 

"*"" 

Telephone 

Service 

Traufetred  to 

(TXie  «ad  PUcrt 

Attending  Phrmlcuui 

**""" 

IbrDr 

Admminf  DUfnotl. 

«!• 

Sex 

Occupation 

IWMI, 

United 

Widow 

R'""°° 

Name  and  Addteu  of  He 

""  ' 

entire  at  Ftletid 

Tel.  Bo.  ReteUTC 

t  Friend 

Rate  pet  Week 

T»  be  Ptta  bj                                                                                                       *""■ 

This  card  is  retained  in  the  business  office  and  is  laid  aside  for  the  day  after  it 
has  been  filled  out  and  until  the  night  clerks  have  had  an  opportunity  to  enter  it 
upon  the  books  in  such  manner  as  we  shall  hereafter  prescribe,  and  when  this 
routine  has  been  gone  through  with  it  is  filed  alphabetically  in  a  card  index  case 
kept  for  the  purpose,  and  it  remains  there  until  the  patient  is  discharged,  where- 
upon it  is  withdrawn  from  that  card  case,  filled  in  properly,  and  filed  alphabetic- 
ally in  another  case  of  the  same  sort  for  "discharged  patients."  It  will  be  con- 
venient to  keep  these  discharged  patients'  cards  when'  they  can  be  easily  reached 
at  least  for  a  month  or  two,  because  questions  often  come  up  about  recently  dis- 
charged patients  and  it  will  be  necessary  to  refer  to  the  card;  afterward  this  card 
can  be  put  away  with  the  archives  of  the  institution  or  entirely  disposed  of,  because 
the  record  of  the  patient  for  all  purposes  has  taken  on  a  permanent  character  along 
other  avenues. 

The  small  admission  card,  containing  the  same  serial  number  as  the  other,  is 
intended  to  accompany  the  patient  upstairs,  and  is  handed  over  to  the  head  nurse 
as  the  order  of  admission,  and  is  the  beginning  of  the  permanent  record  of  the 
patient,  to  be  finally  filled  out  and  returned  to  the  business  office  with  the  bi 


488  OPERATION   OF   THE    HOSPITAL 

of  the  record  when  the  patient  is  discharged,  for  such  disposition  in  the  library  of 
the  institution  as  we  shall  hereafter  describe. 

The  Room  Board. — Before  the  receiving  clerk  can  know  where  a  patient  may 
be  assigned,  or  what  accommodations  of  the  hospital  are  vacant,  he  must  have  ac- 
cess to  some  definitely  carried  out  scheme  of  room  board.  Figure  169  is  a  room 
board  which  seems,  in  an  experience  of  several  years,  to  have  met  every  require- 
ment. The  illustration  explains  the  mechanism  in  detail.  The  board  is  divided 
into  floors,  and  the  rooms  on  these  floors  are  given  either  their  proper  number,  if 
they  be  private  rooms,  or  the  official  designation  if  they  be  wards.  For  the  private 
rooms  there  is  a  card  space  for  a  single  name,  and  these  little  cards  that  fit  conve- 
niently into  the  space  carry  the  name  of  the  patient,  the  name  of  the  physician,  the 
date  of  admission,  and  any  other  memorandum  that  may  seem  necessary.     Under 


Fig.  169. — Room  board. 

the  small  ward  numbers  there  are  spaces  for  the  number  of  beds  in  the  room,  and 
these  spaces  when  occupied  are  filled  out  with  a  card  bearing  the  same  informa- 
tion as  in  the  case  of  private  rooms,  and  the  large  free  wards,  if  there  are  such,  are 
carried  in  the  same  way.  In  the  working  out  of  the  scheme  there  is  a  space  properly 
designated  on  the  board  for  every  bed  in  the  house. 

Two  or  three  colors  in  the  cards  are  advantageous  in  this  board.  White  cards 
indicate  the  bed  or  room  actually  occupied  by  a  patient.  A  red  card  may  be  used 
in  a  space  when  the  room  or  bed  is  engaged,  but  before  the  arrival  of  the  patient. 
A  blue  card  may  show  a  space  in  the  room  or  ward  for  a  bed,  but  indicates  that  there 
is  no  bed  there.  A  card  of  another  color  may  be  used  to  indicate  the  fact  that  the 
room  is  not  in  order  to  be  occupied;  it  may  be  undergoing  repairs  or  it  may  be 
used  at  the  present  time  for  some  other  purpose  than  the  housing  of  patients. 


BUSINESS  MANAGEMENT  489 

In  the  making  up  of  this  board  thought  ought  to  be  taken  for  the  future,  and  it 
should  be  constructed  on  large  enough  lines  to  meet  every  requirement  of  the 
future.  For  instance,  a  room  may  be  occupied  at  the  present  time  by  one  patient, 
and  it  may  be  used  as  a  private  room,  hut  looking  ahead  a  long  way  it  may  be 
conceivable  that  it  might  one  day  be  used  for  two  beds,  or  more,  and  in  such  a  case 
there  ought  to  be  space  on  the  board  opposite  the  number  of  that  room  for  all  the 
beds  that  can  at  any  time  be  placed  in  it  for  use,  and  so  with  the  wards;  a  ward 
may  have  only  four  beds,  and  the  beds  may  be  charged  for  at  a  certain  price  this 
year,  but  in  four  years  from  now  arrangements  may  have  been  vastly  changed, 
and  this  ward  may  be  used  for  six  or  eight  patients,  and  the  board  ought  to  show 
that  the  size  of  the  room  would,  if  necessary,  allow  that  many  beds;  the  extra 
space  in  a  ward  or  room  can  be  indicated  by  a  blue  card  or  by  leaving  the 
space  vacant.  This  mechanism  was  built  especially  for  hospital  purposes,  and 
it  answers  all  of  those  purposes  far  better  than  any  hotel  board  commonly  on 
the  market. 

It  is  well,  in  making  this  room  board,  to  make  it  in  parts,  as  shown  in  the  illus- 
tration. There  is  a  middle  part  half  the  size  of  the  board  which  screws  to  the  wall, 
and  two  other  parts  that  form  the  doors  to  the  board,  and  the  inside  of  these  doors 
when  opened  out  make  up  the  aggregate  of  the  board.  The  purpose  in  making 
the  board  so  that  it  can  be  closed  up  is  a  twofold  one:  first  to  keep  the  dirt  out, 
but  last,  and  very  much  more  important,  to  keep  prying  eyes  away.  Many  patients 
are  very  much  disposed  to  keep  their  presence  in  the  hospital  private,  and  often- 
times it  is  the  express  desire  of  the  physician  that  it  shall  not  be  known  that  the 
patient  is  in  the  house.  It  may  be  a  very  prominent  man,  or  a  society  woman,  or 
the  nature  of  the  disease  may  oftentimes  be  such  that  the  patient  desires  that  his 
or  her  presence  shall  not  be  known,  and  there  are  a  good  many  visitors  in  the  hospi- 
tal who  might  have  access  to  such  a  board  as  this,  and  who  oftentimes  are  not  quite 
discreet,  and  they  should  not  be  tempted  by  having  the  board  wide  open  so  that 
anyone  may  see  the  names  there. 

Disposition  of  Patients'  Clothing  and  Valuables. — Conveniences  in  the  shape 
of  closets  in  the  private  rooms  and,  perhaps,  metallic  lockers  in  the  small  private 
wards  are,  of  course,  provided  in  most  hospitals,  and  either  the  head  nurse  or  the 
patient,  it'  practicable,  will  become  the  custodian  of  the  keys  to  these  closets;  so 
that  the  patient's  clothing  will  not  be  subject  to  removal  by  other  persons.  The 
card  that  has  accompanied  the  private  patient  upstairs  states  specifically  that  the 
institution  will  be  responsible  for  money  and  jewelry  and  valuables  belonging  to 
patients  only  in  the  event  that  these  are  turned  over  to  the  office  and  a  receipt  taken 
therefor.  This  receipt  may  be  kept  either  by  the  patient,  if  practicable,  or  by  the 
head  nurse  on  the  floor,  if  she  has  conveniences  for  keeping  securely  such  papers. 

Sometimes  the  friends  of  patients  choose  to  take  home  whatever  valuables  there 
are,  and  it  would  seem  that  this  is  a  good  practice,  especially  if  the  patient  is  quite 
ill  and  helpless;  but  it  very  often  happens  that  the  friend,  so  solicitous  of  the 
chattels  of  the  patient,  forgets  to  account  For  some  item  and  undertakes  to  bold  the 
institution  responsible  for  its  loss.  It  would  seem,  therefore,  an  extremely  safe 
practice  for  the  institution  to  insist  upon  a  detailed  inventory  of  all  personal 
properly  removed  by  a  friend  of  the  patient,  and  a  receipt  therefor  from  the 
person  removing  the  same.  Such  a  receipt  will  save  embarrassing  inquiry  often 
enough  in  the  courseof  a  year  to  repay  the  trouble  necessitated  in  making  the 
inventory  and  in  obtaining  the  receipt. 

We  come  now  to  the  belongings  of  the  free  patients.  In  some  institutions, 
especially  in  children's  hospitals,  the  parent,  friend,  or  relative  who  brought  the 


490  OPERATION    OF    THE    HOSPITAL 

patient  to  the  hospital  is  compelled  to  take  the  clothing  back  home,  and  the  hospital 
makes  no  provision  for  keeping  the  clothing  of  patients.  It  may  be  well  doubted 
whether  this  is  a  very  good  practice,  especially  in  the  case  of  children.  It  is  often- 
times very  difficult  to  persuade  children's  parents  to  take  their  children  home  after 
their  recovery.  Perhaps  a  child  has  been  ill  for  a  long  time,  and  the  parents  naturally 
agree  that  since  it  got  well  in  the  hospital  it  will  be  better  off  there  for  a  while 
longer,  and  many  excuses  are  made  by  parents  for  refusing  to  take  their  children 
home,  not  the  least  of  which  is  that  they  have  not  clothes  in  which  to  clothe  them, 
and  in  order  to  get  rid  of  the  children  the  institution  is  frequently  compelled  to 
buy  new  clothing,  which  may  or  may  not  be  part  of  the  purpose  of  the  parents 
in  making  the  complaint  of  their  poverty. 

Where  provision  is  made  in  the  institution  for  the  care  of  patients'  clothing,  it 
ought  to  be  a  part  of  the  routine  of  the  admission  of  the  patient  for  the  nurse  or 
orderly  who  gives  the  bath  to  make  out  a  complete  and  detailed  clothes  list,  and  if 
possible  this  list  ought  to  be  signed  and  approved  by  the  patient  himself  or  by 
some  responsible  person  acting  for  him,  because  nurses  and  orderlies  have  been 
known  to  be  careless  in  the  gathering  up  of  patients'  clothing,  and  articles  are 
sometimes  missed  from  the  bundle. 

This  bundle  of  clothing,  either  at  once  or  in  common  with  other  like  bundles 
at  the  close  of  the  day,  should  be  sent  to  the  storekeeper  or  other  person  who  has 
charge  of  patients'  lockers,  and  that  person,  in  the  presence  of  the  orderly  or  nurse 
who  delivers  the  clothing,  ought  to  be  compelled  to  open  the  bundle,  count  and  check 
the  articles  and  tie  it  up  again,  and  he  should  then  receipt  for  the  bundle,  and  this 
receipt,  which  is  written  upon  the  inventoried  clothes  list,  should  be  returned  to  the 
head  nurse,  who  will  keep  it  under  lock  and  key  until  the  patient  is  ordered  dis- 
charged. The  next  step  in  this  procedure  at  the  time  of  discharge  should  be  for 
the  head  nurse,  or  one  of  her  floor  nurses,  or  an  orderly  assigned  for  the  purpose 
to  take  this  list  to  the  business  office,  where  it  should  be  stamped  with  the  approval 
of  the  office  before  the  clothes  can  be  delivered  by  the  custodian.  This  pro- 
cedure will  be  sufficient  announcement  to  the  main  office  that  the  patient  is 
about  to  go  home,  so  that  any  financial  or  other  business  may  be  transacted 
with  him  before  he  leaves  the  institution. 


HOSPITAL  VISITORS 

Conditions  vary  so  greatly  in  different  institutions  that  it  is,  of  course,  impos- 
sible to  lay  down  hard-and-fast  rules  for  visitors,  and  even  the  several  parts  of  a 
general  hospital  cannot  be  regulated  in  that  respect  in  the  same  way.  Visiting 
rules  that  would  be  entirely  proper  for  surgical  patients  would  not  do  at  all  in  the 
children's  department  or  in  the  maternity  section,  and  the  best  we  can  do  is  to  dis- 
cuss a  few  general  principles. 

We  may  begin  with  the  flat  argument  that  it  would  be  best  for  all  sick  people 
if  all  visiting  could  be  prohibited,  and  it  is  a  recognized  situation  in  nearly  every 
hospital  that  has  visiting  days  that  temperatures  are  higher  at  night  on  the  visiting 
days  than  at  other  times,  all  else  being  equal,  and  this  is  due  to  the  excitement 
caused  by  visitors,  not  alone  one's  own  visitors,  but  those  who  come  to  see  other 
people. 

Visitors  in  the  hospital  very  frequently  feel  that  they  have  fulfilled  only  half 
of  their  mission  if  they  do  not  go  about  the  wards  of  the  institution  talking  with 
and  offering  sympathy  to  patients  at  large,  and  especially  if  there  is  some  particu- 
larly sick  person  near  the  one  they  have  come  to  visit;. the  visitors  seem  to  focus 


BUSINESS    MANAGEMENT  4'J1 

their  attention  upon  that  one,  and  instead  of  helping  they  almost  invariably  retard 
the  patient's  recovery,  and  oftentimes  excite  him  to  a  serious  extent. 

In  considering  the  visiting  question,  therefore,  we  have  two  or  three  fundamental 
ideas  in  the  foreground;  one  of  them  is  that  we  ought  to  restrict  visiting  as  much  as 
possible;  and  we  ought,  in  any  event,  to  limit  visits  to  the  one  patient  whom  visi- 
tors come  to  see;  anil  visits  should  be  as  short  as  possible,  and  wherever  it  can  be 
done  each  patient  should  be  restricted  to  one  or  two  or  at  least  a  minimum  number 
of  visitors.  It  very  often  happens,  where  the  visiting  hours  last  during  the  whole 
afternoon,  that  a  patient  will  have  a  continuous  stream  of  visitors,  only  one  or 
two  or  three  at  a  time  perhaps,  and  when  new  friends  come  those  who  have  been 
there  a  while  get  up  and  leave.  And  very  often  visitors  are  indignant  if  the  hospi- 
tal presumes  to  judge  how  many  visitors  a  patient  should  have. 

Oftentimes  the  doctor  is  of  no  assistance  in  restricting  the  number  of  visitors. 
When  he  is  at  the  hospital,  he  is  likely  to  give  peremptory  orders  restricting  visitors 
to  two  or  three  members  of  the  family,  or  even  one,  and  when  the  doctor's  orders 
are  cited  to  visitors  later  on  in  the  day  they  will  bring  such  pressure  upon  him  that 
he  is  compelled  to  raise  the  restriction,  and  then  find  fault  with  the  hospital  authori- 
ties for  his  having  been  compelled  to  do  so. 

In  some  institutions  it  is  possible  to  have  only  one  or  two  visiting  days  a  week 
and  one  or  two  hours  on  each  day,  and  to  limit  the  number  of  visitors  to  one  or  two 
people.  Such  conditions  as  these  are  ideal,  but  they  are  almost  impossible  in  most 
institutions,  and  invariably  so  in  institutions  that  have  a  clientele  largely  made  up 
of  pay  patients. 

Let  us  now  consider  the  question  of  visitors  in  the  several  parts  of  the  hospital 
rather  more  in  detail. 

Visitors  to  Private  Patients. — It  would  seem  that  the  hospital  has  a  right  to 
throw  the  whole  matter  of  visitors  upon  the  shoulders  of  attending  physicians  in 
the  case  of  private  patients,  and  if  it  can  do  this  the  institution  escapes  a  large 
measure  of  responsibility  and  an  immense  amount  of  trouble,  because,  after  all,  the 
question  of  visitors  is  a  part  of  the  treatment  of  the  case,  and  the  doctor  should  be 
the  final  judge  as  to  what  is  best  for  his  patients,  and  he  is  presumed  to  have  cour- 
age enough  to  give  the  proper  orders. 

Visitors  in  private  rooms  present  a  problem  even  easier  of  solution  than  in  the 
private  wards,  because  in  the  one  case  visitors  do  not  interfere  with  anyone  else; 
they  go  into  the  patient's  room  and  remain  there  until  they  are  ready  to  leave  the 
institution;  so  that  the  question  of  hours  and  the  number  of  people  that  ought  to 
be  admitted  to  private  rooms  is  one  entirely  within  the  realm  of  the  doctor's  orders. 

In  the  private  wards,  however,  there  is  presented  the  additional  difficulty  of 
interference  by  visitors  with  the  rights  of  other  patients  than  the  one  they  came  to 
visit,  and  there  is  presented  a  responsibility  that  the  institution  itself  cannot 
escape,  and  the  orders  of  a  physician  attending  one  patient  should  not  be  permit  in  I 
to  invade  the  rights  and  interfere  with  the  welfare  of  any  other  patient  in  the 
ward.  In  the  private  rooms,  therefore,  we  may  consider  it  almost  an  established 
necessity  to  allow  patients  to  receive  visitors,  subject  to  the  doctor's  orders,  at 
almost  any  time  of  the  twenty-four  hours,  and  concerning  the  private  wards  there 
is  an  established  practice  in  a  good  many  institutions  that  are  well  conducted  to 
restrict  the  visiting  hours  to  the  afternoon  only,  say  from  1  to  5  o'clock,  as  being  a 
fair  restriction  in  the  interest  of  all  the  patients  in  the  ward. 

Visitors  in  Large  Wards. — The  real  problem  concerning  visitors  presents  itself 
in  connection  with  the  large  wards,  whether  the  patients  are  tree  or  pay  a  small 
amount  in  the  hospital.     It  goes  without  saying  that  indiscriminate  and  continu- 


492  OPERATION    OF   THE    HOSPITAL 

ous  visiting  in  the  large  wards  cannot  be  permitted,  because  visitors  create  a  cer- 
tain amount  of  disturbance  and  excitement,  and  if  one  patient  is  allowed  to  see 
visitors,  others  must  be  allowed  the  same  privilege,  and  if  that  principle  is  carried 
out  there  will  be  a  stream  of  visitors  all  day  and  into  the  night. 

Where  the  institution  receives  a  large  proportion  of  free  patients  and  gets 
nothing  from  these  patients  or  from  anybody  specially  interested  in  them,  but  gives 
everything  to  them  without  any  return,  rather  fast  rules  can  be  set  down  tempered 
only  by  humanitarianism,  that  is,  the  human  right  of  sick  people  to  see  their 
friends  whether  they  be  rich  or  poor;  and  in  such  institutions  the  visiting  hours 
can  be  cut  to  perhaps  two  hours  twice  a  week,  without  any  right  of  complaint  either 
on  the  part  of  the  public  or  the  sick  people,  and  such  restrictions  will  go  a  long  way 
toward  aiding  the  patient's  recovery. 

There  are  a  good  many  institutions  that  have  some  definite  problem  of  work  as 
the  inspiration  behind  their  support,  some  particular  class  of  poor  people  in  whom 
the  supporters  of  the  hospital  are  specially  and  humanly  interested,  and  unless 
the  visiting  hours  in  such  institutions  are  generous  there  will  be  so  much  com- 
plaint that  the  support  of  the  hospital  is  likely  to  suffer,  and  it  may  be  necessary 
in  such  cases  to  open  the  doors  to  visitors  in  the  large  wards  for  two  or  three  hours 
each  day  in  the  week. 

Where  a  patient  in  a  large  ward  is  so  ill  that  the  excitement  of  visitors  about  the 
other  beds  will  be  a  positive  detriment,  a  screen  may  be  thrown  about  the  bed, 
and  if  visitors  are  kept  under  proper  discipline  the  excitement  and  hurtfulness  of 
the  visiting  hours  will  be  minimized  greatly;  sometimes  it  will  be  necessary  to  place 
an  exceptionally  sick  patient  in  the  quiet  room  or  in  some  isolated  place  during 
the  visiting  hours,  and  this  will  be  particularly  true  in  the  children's  ward. 

Visitors  in  Maternity. — No  matter  what  the  institution  or  how  it  is  conducted 
or  whence  its  support  is  derived,  there  is  a  definite  duty  on  the  part  of  the  hospital 
administration  to  ruthlessly  limit  the  visitors  in  the  maternity  department  of  the 
institution.  It  is  true  the  mothers  and  babes  are  not  sick  people,  and  after  the 
first  two  or  three  days  following  the  birth  of  the  child  the  mothers  evince  a  good 
deal  of  curiosity  about  the  outside  world,  and  they  like  to  have  visitors,  and 
oftentimes  fret  and  complain  if  they  are  not  permitted  to  do  so,  but  visitors  are 
actually  hurtful  to  women  in  childbed,  and  their  presence  often  starts  a  tempera- 
ture that  is  apt  to  find  a  focus  somewhere  and  be  the  beginning  of  an  infection  that 
may  be  serious. 

There  is  an  immense  amount  of  curiosity  on  the  part  of  the  public  concerning 
the  maternity  department  of  a  hospital,  and  this  is  especially  true  with  women,  who 
will  oftentimes  gain  access  to  the  maternity  department  under  the  flimsiest  excuses, 
merely  to  gratify  an  idle  curiosity  regarding  the  women  and  their  babies.  In  other 
parts  of  the  hospital  it  is  not  well  for  patients  to  have  too  many  visitors  or  to  have 
them  too  often.  In  the  maternity  department,  however,  there  is  an  absolute  neces- 
sity to  limit  the  visiting,  and  in  a  number  of  excellently  conducted  maternity  insti- 
tutions the  visiting  in  that  department  is  restricted  with  an  iron  hand  to  the  hus- 
band of  the  patient  and,  perhaps,  her  parents.  As  in  other  parts  of  the  hospital, 
this  rule  applied  to  private  rooms  and  even  the  private  wards  cannot  be  drawn  quite 
so  finely  as  in  the  case  of  the  large  maternity  wards,  and  the  visiting  hours  in  those 
private  sections  will  oftentimes  have  to  be  lengthened. 

There  is  no  doubt  that  a  woman  in  childbirth  is  improved,  at  least  mentally,  by 
having  her  husband  and  perhaps  her  parents  visit  her  as  frequently  as  possible, 
especially  after  the  first  two  or  three  days,  and  if  she  is  occupying  a  private  room 
or  a  small  ward  no  great  harm  can  follow. 


BUSINESS   MANAGEMENT  493 

But  in  the  large  wards  the  rule  will  have  to  be  mandatory.  It  would  seem  that 
a  husband  and  father  ought  to  be  permitted  to  see  his  wife  and  child  as  soon  as  she 
is  comfortably  in  bed,  and  he  ought  to  be  permitted  to  visit  with  her  for  a  while  and 
it  will  be  a  great  comfort  to  the  patient.  But  after  that  first  visit  there  is  no 
particular  reason  why  the  husband  should  come  oftener  than  two  or  three  times 
more  during  the  patient's  stay  in  the  institution.  So  if  the  visiting  can  be  limited 
to,  say,  two  hours  twice  a  week,  that  would  seem  to  be  abundant.  Whenever  a 
woman  has  a  baby  in  a  hospital,  her  kin  and  all  her  friends  want  to  see  her,  and 
especially  they  want  to  see  the  new  baby,  and  if  permitted  they  will  keep  the  patient 
in  an  excitement  that  is  positively  harmful,  and  that  will  very  many  times  result 
in  some  complication  of  childbirth. 

The  most  difficult  thing  to  control  concerning  visitors  in  a  maternity  depart- 
ment has  to  do  with  the  visits  of  children.  As  soon  as  a  babe  is  born  to  a  woman 
who  has  other  children  at  home,  she  wants  the  other  children  to  see  the  newcomer, 
and  she  will  generally  raise  a  row  if  it  is  not  permitted;  but  it  ought  not  to  be 
permitted  for  children  to  visit  in  the  maternity  department  of  the  hospital  under 
any  circumstances,  and  unless  an  ironclad,  inflexible,  and  irrevocable  rule  is  estab- 
lished prohibiting  children  from  visiting  the  section  the  whole- rule  is  lost.  If  an 
exception  is  made  in  favor  of  a  rich  banker's  wife  and  she  is  permitted  to  have  her 
children  in  her  private  roon,  then  the  private  patient  of  moderate  means  will  exact 
the  same  privilege  and  will  be  highly  incensed  if  the  rule  is  drawn  against  her;  and 
if  she,  too,  is  allowed  to  see  her  other  children,  then  the  patients  in  the  private 
wards  will  exact  the  same  privilege,  and  so  on  to  the  large  public  wards,  so  that  it 
would  seem  imperative  to  prohibit  the  visits  of  children  anywhere  in  the  depart- 
ment. 

Why?  Because  children  from  the  outside  oftentimes  have  some  communicable 
disease  of  childhood  incubating  in  their  systems,  and  the  little  new  babies  are  veri- 
table sponges  for  absorbing  anything  in  the  nature  of  an  infection.  If  the  depart- 
ment has  any  considerable  service,  that  is,  if  there  are  many  cases  of  labor,  and  hence, 
it'  many  children  are  to  be  permitted  to  visit  in  the  department,  it  is  a  moral  cer- 
tainty that  about  so  often  some  child  will  light  up  a  communicable  infection  such 
as  measles,  scarlet  fever,  or  even  diphtheria,  and  not  only  jeopardize  the  lives  and 
health  of  the  new  babies  and  their  mothers,  but  bring  the  department  into  dis- 
repute and  destroy  its  power  for  usefulness. 

It  is  the  experience  of  some  of  us  that  the  doctors  will  fight  this  rule  against  child 
visitors,  and  manifestly  they  will  do  it  to  curry  favor  with  their  patients,  bul  it 
is  also  the  experience  of  some  of  us  that  if  the  rule  is  made  inflexible  and  unexcep- 
tionable the  physicians  who  frequent  the  department  will  eventually  have  a  respect 
for  it,  and  they  will  feel  all  the  safer  in  bringing  their  patients  there,  and  they  will 
oftentimes  use  that  very  rule  as  one  of  the  principal  arguments  with  a  patient  why 
she  should  go  to  that  particular  hospital  for  her  maternity,  rather  than  to  some 
other  institution  whose  rules  are  a  little  more  lax  and  flexible. 

Every  non-medical  visitor  in  the  obstetric  department  of  an  institution  ought 
to  be  compelled  to  wear  a  hospital  visitor's  gown,  preferably  one  of  the  flour-sack 
kind  that  has  no  sleeves,  and  that  is  put  on  like  a  woman's  skirt  over  the  head,  with 
a  hole  just  large  enough  for  the  head  to  slip  through,  and  that  will  reach  almost  to 
the  floor  (Fig.  170).  In  this  way  visitors  are  not  permitted  to  use  their  hands, 
which  are  kept  under  the  gown,  and  they  cannot  meddle  with  things  that  do  not 
concern  them,  either  in  con  nee  i  i<  in  with  their  own  mother  and  babe  or  in  connection 
with  the  ward  service,  instruments,  and  apparatus.     Visitors  object  to  these  gowns 

at  first,  and  their  use  must  he  (plite  as  inflexible  a  rule  as  that  concerning   the  visits 


494 


OPERATION    OF   THE    HOSPITAL 


of  children,  but  after  a  while,  when  the  rule  is  well  established,  visitors  appreciate 
the  necessity  for  it. 

In  the  Michael  Reese  Hospital  Maternity  Department  93  babies  were  born 
during  the  fiscal  year  of  1906  and  1907.  At  the  end  of  that  year  a  new  regime  was 
established  and  the  inviolable  rules  above  cited  were  inaugurated,  and  it  was 
freely  predicted  that  the  department  would  be  destroyed.  Instead  of  that,  however, 
the  service  there  now  averages  more  than  90  labor  cases  per  month,  or  twelve  times 
what  it  was  five  years  ago,  and  nearly  half  of  these  1000  patients  per  year  are  women 
who  can  afford  to  pay  for  a  private  room  from  $25  per  week  up  to  $100. 

Thus  is  presented  a  plain  argument  that  a 
rigid  conduct  of  a  maternity  department  that 
stands  for  asepsis,  cleanliness,  and  healthful- 
ness  is  appreciated  by  the  public  in  the  long 
run. 

Visitors  in  the  Children's  Hospital. — It 
would  seem  at  a  first  glance  that  the  visiting 
of  parents  to  children  in  the  hospital  would 
aid  their  recovery,  but  this  is  not  true,  and 
sick  children  do  far  better  wlien  their  parents 
keep  away.  Whatever  may  be  said  about 
parental  kindness,  it  is  at  least  true  that 
parents  who  send  their  children  to  the  hospital 
are  not  the  best  possible  influence  that  can  be 
brought  to  bear  on  them  when  they  are  sick. 
Perhaps  the  reason  why  a  good  many  of  them 
are  sent  to  the  hospital  rather  than  kept  at 
home  is  because  the  parents,  for  one  reason  or 
another,  have  not  nursed  them  wisely  and 
have  not  been  best  calculated  to  aid  in  their 
recovery.  In  any  event,  experience  has  demon- 
strated that  a  vast  majority  of  parents  who 
visit  their  sick  children  in  the  hospital  bring 
something  in  their  pockets  which  they  surrep- 
titiously give  them  to  eat  that  is  not  good 
for  them;  in  addition  to  this,  parents  nearly 
always  resent  any  hospital  practice  that  seems 
to  render  the  child  uncomfortable,  and  these 
visitors  give  the  nurses  a  great  deal  of  trouble. 
They  have  been  known  to  take  the  children 
out  of  hot-packs,  prevent  the  giving  of  enemas, 
and  frequently  interfere  even  with  the  taking 
of  temperatures.  If  they  are  in  the  hospital 
during  the  feeding  hours,  it  is  a  common 
complaint  that  the  children  are  being  starved  or  that  they  are  not  accustomed 
to  the  kind  of  food  they  are  getting. 

Parents,  generally,  will  refuse  to  leave  their  children  at  a  hospital  if  they 
camiot  visit  them  frequently,  and  one  reason  that  they  give  is  that  the  children 
make  themselves  sick  crying  if  they,  the  parents,  are  not  there,  and  there  is  ap- 
parently a  good  reason  for  their  feeling  in  this  regard.  When  the  parents  visit  the 
hospital,  generally  speaking,  they  will  find  the  child  in  a  good  humor  if  it  is  not  too 
sick,  and  the  child  will  enjoy  the  visit  with  the  parent,  but  when  the  parent  leaves 


Fig.  170. — Visitor's  gown. 


BUSINESS   MANAGEMENT  495 

the  room  to  go  home  the  child  begins  to  wail,  and  the  parent  will  hear  the  child 
crying  sometimes  until  she  is  clear  away  from  the  building,  and  she  is,  therefore, 

under  the  impression  that  the  child  will  continue  to  cry  until  -he  returns.  <  tften- 
times  these  children  do  cry  for  an  hour  after  their -mothers  leave  them,  and  then 
they  will  not  cry  again  or  even  ask  for  the  parents  until  they  come  again,  when 
the  performance  is  repeated. 

Visitors  of  a  certain  kind  ought  to  be  made  welcome  in  the  children's  depart- 
ment; not  the  mothers  of  children,  because  they  create  a  certain  ferment  there  and 
interfere  with  rather  than  better  the  condition  of  the  children.  But  in  some  insti- 
tutions  there  are  certain  young  laches'  societies  whose  members  take  turns  and 
are  assigned  alternately  to  visit  the  hospital  and  entertain  the  children.  If  there  are 
playrooms,  and  hooks  and  toys  and  pictures,  the  children  get  an  immense  lot  out  of 
the  visits  of  these  young  ladies,  and  it  is  very  certain  that  the  young  ladies  get  a  lot 
out  of  their  work  at  the  hospital;  it  is  a  question  which  benefits  the  most  by  the 
entertainment.  In  any  event,  if  there  are  regular  hours  for  the  visits  of  these  young 
ladies  during  which  the  children  can  be  entertained,  they  will  come  to  look  forward 
to  those  visiting  hours  with  an  immense  amount  of  pleasure,  and  if  there  is  a  roof- 
garden  or  some  out-of-door  place  where  the  little  entertainments  can  be  held  the 
children  will  get  recreation,  fresh  air,  and  great  benefit. 

It  would  seem  that  after  a  while  the  young  ladies  would  get  tired  of  their  self- 
imposed  task  as  nursery  maids  and  children's  entertainers,  but  that  appears  not  to 
be  the  case.  In  one  or  two  institutions  in  which  this  practice  prevails  that  can  be 
cited  as  illustrations  young  ladies'  societies,  that  could  be  hardly  held  together 
when  sewing  and  other  charity  work  was  the  inspiration,  have  grown  so  amazingly 
when  the  hospital  work  was  inaugurated  that  a  limit  had  to  be  set  to  the  member- 
ship. 

Social  Visits  of  Physicians. — Nearly  every  institution  is  presented  occasionally 
with  the  ethical  problem  set  up  by  the  social  visits  of  physicians  to  the  patients 
of  other  physicians.  It  may  seem  that  this  is  an  insignificant  matter,  but  expe- 
rience has  demonstrated  that  it  is  not  either  simple  or  inconsequential.  We  all 
know  that  there  are  doctors  in  every  walk  of  life  almost  who  make  a  practice  of 
securing  patients  through  social,  political,  and  religious  influence,  and  these  gentry 
frequently  ply  their  trade  within  the  walls  of  the  hospital. 

Mrs.  Jones  is  sick  and  the  ladies  of  her  church  circles  are  intensely  interested 
in  her  welfare,  and  they  discuss  her  case  perhaps  in  the  pcrsence  of  the  minister's 
wife,  who  happens  to  be  an  intimate  friend  of  a  neighboring  doctor  or  his  wife. 
There  is  another  physician  treating  Mrs.  Jones,  perhaps  a  most  competent  man. 
Mr.  Jones  is  anxious  and  uneasy  and  expresses  his  concern  to  the  minister  or  the 
minister's  wife,  and  perhaps  names  over  a  lot  of  symptoms  from  which  Mrs.  Jones 
seems  to  he  suffering;  whereupon  the  good  minister  and  his  wife  proceed  to  dilate 
upon  the  great  ability  of  their  friend  and  neighbor  doctor,  and  perhaps  they  are 
enabled  to  cite  a  long  list  of  cases  apparently  very  similar  thai  that  worthy  medical 
man  has  cured;  and  it  is  finally  suggested  that  he  be  asked  to  pay  Mrs.  Jones 
"just  a  social  visit."  The  next  step  is  For  the  visitor  to  find  fault  with  the  line  of 
treatment  employed  in  the  case  of  -Mrs.  Jones,  and  eventually  he  succeeds  m  agitat- 
ing the  whole  circle  of  friends,  if,  indeed,  he  does  not  actually  succeed  in  replacing 
the  attendant   physician  in  the  case. 

This  is  but  a  fair  illustration  of  what  is  practised  daily  in  connection  with  al- 
most every  hospital.    The  question  is  how  to  meet  such  a  contingency;  of  course. 

the  institution  would  not  allow   an    outside  physician  to  c< in  and  review  the 

orders  of  the  attending  physician,  but  it  IS  not  a  difficult  thing  For  a  medical  visi- 


496  OPERATION   OF   THE    HOSPITAL 

tor  on  a  social  call  to  get  hold  of  the  record  and  post  himself  as  to  what  is  being 
done,  at  least  sufficiently  to  find  fault  with  it  after  he  gets  home. 

It  seems  that  the  only  way  to  master  this  problem  is  to  ask  medical  visitors 
to  patients  not  their  own  to  place  themselves  first  in  touch  with  the  attending  physi- 
cian in  the  case,  and  it  can  be  fairly  pointed  out  that  that  will  be  the  method  most 
pleasing  to  the  ethics  of  the  case;  and  in  the  event  that  a  medical  man  should 
object  to  express  his  wish  to  visit  a  patient  to  the  attending  physician  in  the  case, 
it  would  seem  that  such  a  man  could  be  refused  admission  to  the  patient  without 
very  much  ceremony.  And  when  a  medical  man  is  finally  permitted  to  pay  a  social 
visit  to  a  patient  he  ought  to  be  accompanied  by  the  house  physician  on  the  case, 
this  for  the  protection  of  everybody  concerned. 

Of  course,  no  self-respecting  physician  will  consent  to  visit  professionally  the 
patient  of  another  physician  until  all  the  ethical  requirements  have  been  com- 
plied with;  that  is  to  say,  a  patient  or  the  responsible  member  of  his  family  has  a 
perfect  right  to  ask  the  attending  physician  for  consultation  at  any  time,  and  if 
the  proposed  consultant  is  unexceptionable,  the  attendant  must  agree  to  it,  and 
himself  ask  the  consultant  to  meet  him  in  the  case.  Or  a  patient  has  a  perfect  right 
at  any  time  to  dismiss  a  physician  and  employ  some  one  else,  and  the  only  thing  to 
be  done  is  for  the  patient  or  some  one  representing  him  to  tell  the  attendant  he 
is  no  longer  wanted,  pay  him  off,  and  secure  the  services  of  some  one  else,  and  the 
new  attendant  will  be  perfectly  satisfied  when  this  course  is  followed. 

A  Device  for  Handling  Visitors. — Naturally,  visitors  to  private-room  patients 
may  use  a  visiting  card  of  their  own,  which  is  sent  to  the  room  of  the  patient  in 
advance,  so  that  the  prospective  visitor  may  learn  whether  the  visit  will  be  agree- 
able or  not,  but  in  the  wards  of  the  institution  it  has  always  been  an  extremely 
difficult  matter  to  maintain  a  check  on  the  number  of  visitors  to  each  patient.  In 
the  Michael  Reese  Hospital  a  board  has  been  devised,  photographs  of  which  are 
shown  herewith  (Figs.  171,  172). 

This  board  is  set  up  at  the  desk  in  the  main  hall,  where  visitors  must  receive 
their  credentials  before  going  into  the  hospital  proper.  On  this  board  are  figures 
representing  all  the  wards  of  the  institution,  and  beneath  the  number  of  the  ward 
are  small  pockets  made  of  vulcanized  rubber  or  some  such  material,  the  number 
of  pockets  for  each  ward  corresponding  to  the  number  of  beds  in  the  ward,  and  in 
each  of  these  pockets  are  three  cards;  one  projects  above  the  other  two  and  con- 
tains merely  the  name  of  the  patient  occupying  the  bed.  In  front  of  this  name 
card  and  a  little  shorter,  so  that  they  do  not  hide  the  name,  are  two  other  cards, 
the  regular  visitor's  cards  of  the  institution,  and  these  cards  also  contain  the  name 
of  the  patient  written  lightly  in  lead  pencil  so  that  it  can  be  easily  erased  for  use  of 
the  card  elsewhere.  It  is  the  practice  to  allow  two  visitors  only  at  one  time,  and 
when  the  two  cards  apportioned  to  the  patient  have  been  distributed  to  visitors 
no  other  visitor  can  see  that  patient  until  the  cards  are  again  returned  to  the  board, 
as  evidence  that  the  visitors  have  gone.  If  it  is  ordered  that  the  patient  shall  have 
only  two  visitors  during  the  day,  the  cards  will  not  be  returned  to  the  rack  until 
night.  If  the  patient  can  have  as  many  visitors  as  choose  to  call  the  cards  are 
immediately  returned  to  the  rack  on  their  surrender  by  visitors  as  they  leave,  and 
they  can  then  be  given  out  to  other  visitors.  Sometimes  the  patient  is  not  to  have 
any  visitors  at  all,  by  the  doctor's  orders,  and  in  such  case  a  note  to  that  effect 
is  stuck  in  the  pocket  against  the  patient's  name,  so  that  visitors  may  be  refused 
when  they  present  themselves.  Sometimes  it  is  necessary  for  the  business  office 
to  see  the  friends  of  the  patient  for  financial  or  other  reasons,  and  in  that  case  a 
note  to  that  effect  is  slipped  into  the  pocket  against  the  patient's  name,  so  that 


BUSINESS   MANAGEMENT 


497 


any  one  who  calls  to  sec  the  patient  can  lie  sent  to  the  office;  or  perhaps  ii  i-  the 
house  physician  who  wishes  to  see  the  friends  of  a  patient  to  present  some  problem 
or  make  some  announcement,  and  the  note  in  the  pocket  will  request  that  the 
house  physician  be  sent  for  when  a  visitor  comes. 

Before  this  visitor's  board  was  installed  visitor's  cards  were  collected  by  the 
elevator  operator  as  visitors  went  upstairs.  Naturally,  this  practice  could  not  be 
continued  after  its  adoption,  since  the  visitors  themselves  were  required  to  return 
the  card  to  the  rack,  and  upon  each  visiting  card  there  is  a  printed  statement  to  the 


Fig.  171.  Fig.  172. 

Device  for  handling  visitors.     The  illustration  in  the  lower  right-hand  comer  -hows  detail. 

effect  thai  the  patient  will  not  receive  other  visitors  until  this  card  is  returned  to 
the  person  in  charge  of  the  board. 

This  board  litis  served  an  extremely  useful  purpose;  it  has  served  materially 
to  limit  the  number  of  visitors  to  each  patient  at  one  time;  if  there  are  several 
visitors  to  a  patient  at  one  time,  some  of  them  are  almost  certain  to  wander  about 
the  corridors  and  other  wards  and  to  make  of  themselves  a  general  nuisance;  the 

net  result  of  this  particular  board  is  that  several  hundred  visitors  can  be  handled 
on  each  visiting  day  during  the  two  hours  in  an  orderly  and  proper  manner,  and 

thus  a  large  part  of  the  former  terror  of  the  visiting  hoUTS  ha-  been  losl  to  the  QUISeS 

and  interns  and  other  attendants  in  the  hospital. 

32 


498  OPERATION    OF    THE    HOSPITAL 

THE  HOSPITAL  TELEPHONE 

To  the  casual  observer  it  would  seem  an  extremely  simple  matter  to  make  rules 
for  the  performance  of  the  telephone  sendee  of  a  hospital;  but  this  is  not  true,  and 
the  telephone  sendee  in  a  large  general  hospital  or  in  any  institution  frequented  by 
a  good  many  physicians  and  patronized  by  a  considerable  number  of  well-to-do 
people  is  a  complex  and  technical  affair. 

The  functions  of  the  telephone  are  easily  divisible  in  a  general  hospital;  nearly 
all  outgoing  calls  have  to  do  with  the  purchase  of  supplies  or  business  concerning 
supplies  for  the  hospital,  unless  there  is  a  nurses'  register  in  the  institution  connected 
with  a  training-school,  in  which  case  there  is  a  good  deal  of  telephoning  about  gradu- 
ate specials.  The  only  other  outgoing  work  of  any  moment  concerns  the  condition 
of  patients  in  the  shape  of  information  transmitted  from  the  interns  or  house 
physicians  to  the  visiting  physicians  who  have  patients  in  the  institution;  but  all 
this  work  taken  together  might  be  done  over  one  trunk  line,  and  because  the  out- 
going work  is  performed  by  employees  or  other  persons  in  the  institution  subject 
to  discipline  the  sendee  could  be  easily  regulated  so  that  the  trunk  line  would  be 
comfortably  busy  most  of  the  time,  but  never  under  any  very  heavy  pressure. 

The  onerous,  exacting,  and  annoying  telephone  sendee  of  a  hospital  concerns 
messages  into  the  house  from  anxious,  inquiring  friends,  and  unless  a  very  tight  rein 
is  kept  on  this  part  of  the  sendee  it  is  likely  to  assume  an  infinite  number  of  embar- 
rassing phases,  and  especially  is  this  true  if  a  considerable  part  of  the  clientele  of 
the  institution  is  made  up  of  well-to-do  people.  Some  relative  of  a  patient  will  call 
for  the  special  nurse  on  the  case,  not  only  to  inquire  about  the  condition  of  the 
patient,  but  to  use  her  as  the  intermediary  for  the  conduct  of  all  sorts  of  domestic 
business  between  the  patient  in  the  hospital  and  the  home. 

In  a  good  many  institutions  there  are  portable  telephones  to  fit  into  wall  plugs 
in  the  rooms  of  patients,  and  where  patients  have  access  to  the  phone  themselves 
they  grow  readily  into  the  habit  of  visiting  over  the  phone  and  carrying  on  long 
conversations  with  their  friends  and  with  their  children. 

Some  institutions  are  so  situated  that  they  are  rather  helpless  in  enforcing  any- 
thing like  a  discipline  in  regard  to  a  telephone  sendee,  and  are  under  a  moral 
compulsion  to  allow  the  service  to  grow  until  it  is  wholly  inefficient,  and  they  then 
have  the  other  horn  of  the  dilemma,  the  continuous  complaints  on  the  part  of  the 
public,  physicians,  and  patients. 

It  seems  that  the  only  cure  for  the  evils  of  an  overburdened  telephone  service 
in  the  hospital  is  a  strict  discipline  and  a  limitation  of  the  use  of  the  sendee  within 
pretty  narrow  bounds.  For  instance,  it  has  been  found  in  some  institutions  that 
are  very  well  conducted  that  a  slot  telephone  in  the  physicians'  locker  room  will 
do  a  good  deal  to  prevent  visiting  doctors  from  paying  some  of  their  morning  calls 
over  the  telephone,  and  with  slot  telephones  elsewhere  in  the  house,  where  conva- 
lescent patients  and  the  friends  of  patients  can  use  the  pay  machine,  another  econ- 
omy and  restriction  can  be  practised. 

The  nurses  and  interns  are  great  abusers  of  the  privileges  of  a  telephone.  Both 
of  these  classes  of  young  people  are  fond  of  visiting  over  the  phone,  but  they  are, 
as  a  rule,  not  very  well  supplied  with  cash,  and  if  they  are  compelled  to  pay  a  nickel 
to  telephone  the  sendee  will  be  properly  limited  in  that  way. 

If  the  telephone  sendee  is  a  good  deal  of  a  nuisance  in  the  hospital,  it  also 
sen_es  some  extremely  useful  purposes,  besides  being  a  medium  for  the  transaction 
of  the  business  of  the  institution  with  the  outside  community.  One  of  these  avenues 
of  usefulness  is  as  a  convenience  for  busy  visiting  physicians.  In  the  Michael 
Reese  Hospital,  for  instance,  the  switchboard  operator  acts  to  all  intents  and  pur- 


BUSINESS   MANAGEMENT 


49«J 


poses  as  the  office  attendant  to  the  visiting  physicians.  There  is  a  physicians' 
register  located  in  the  neighborhood  of  the  switchboard,  where  the  visiting  physi- 
cians register  as  they  come  into  the  institution  to  make  rounds,  and  if  their  patients 
or  their  office  call  they  can  be  reached  at  the  hospital.  The  switchboard  operator 
takes  the  message,  fills  in  the  blanks  of  a  printed  form  kept  for  the  purpose,  Kivhig 
name  and  address  and  telephone  number  of  the  caller,  and,  in  rare  instances,  the 
sense  of  the  message  to  be  conveyed;  and  if  the  doctor  has  his  own  registry  or  hat 
hook  the  printed  slip  can  be  attached  to  it  so  he  will  get  it  when  he  comes  in.  In 
this  way  many  physicians  out  making  their  calls  grow  accustomed  to  drop  in  at  the 
hospital,  even  when  they  have  no  business  there,  and  thus  they  come  to  regard  the 
institution  as  a  part  of  their  daily  routine,  and  the  next  step  will  be  for  them  to 
send  their  patients  there.  An  immense  amount  of  the  telephone  business  of  the 
hospital  can  be  transacted  directly  with  the  switchboard  operator  in  conjunction 
with  the  "condition  book,''  which  we  shall  take  up  more  in  detail  presently. 

THE  PHYSICIANS'  REGISTER 
A  form  of  "in-and-out"  register  for  visiting  physicians  is  shown  in  Fig.  173. 
This  register  has  a  sliding  "in"  and  "out"  plate  for  each  physician,  with  his  name 


Fip.  173. — Register  for  visiting  physicians. 

plainly  written  on  it.  so  thai  the  telephone  operator  can  see  it  easily;  next  to  the 
name  is  a  pocket  large  enough  to  hold  an  ordinary  envelope  or  note:  so  that   any 


500  OPERATION    OF   THE    HOSPITAL 

one  who  wishes  to  communicate  with  the  doctor  can  leave  a  note  where  he  is 
sure  to  get  it  when  he  enters  the  building.  This  board  is  made  by  the  Universal 
Register  Co.,  of  Chicago,  from  a  design  furnished  by  the  Michael  Reese  Hospital. 
In  some  institutions  only  a  book  register  is  used,  with  a  space  for  the  name  of  the 
physician,  the  hour  or  minute  at  which  he  enters  the  institution,  and  a  similar  space 
to  be  filled  in  as  he  leaves.  The  push  register  is  the  most  convenient  form,  and  while 
it  is  doubtful  whether  the  difference  in  time  between  putting  down  two  or  three 
figures  and  pushing  the  board  amount  to  anything,  physicians  regard  it  as  a  hard- 
ship if  they  are  asked  to  sign  their  names,  and  so  the  push  board  is  used  instead, 
and  is  an  index  for  the  telephone  switchboard  operator  to  know  whether  the  doctor 
is  in  the  house,  so  that  she  can  ring  up  some  particular  section  of  the  institution 
and  allow  him  to  talk  to  his  "party." 

The  registry  book  is  a  most  serviceable  institution  under  some  conditions 
and  is  almost  necessary;  for  instance,  in  the  great  charity  hospitals  it  is  always  a 
difficult  thing  to  get  staff  members  to  attend  regularly  and  promptly,  and  the  city 
or  county  authorities  are  enabled  frequently  to  use  the  in-and-out  register  as  a 
permanent  record  of  the  attendance  or  non-attendance  of  men  who  hold  staff 
positions  and  who  are  supposed  to  give  their  services  at  certain  hours  on  certain 
days.  Not  long  since  a  considerable  number  of  men  attached  to  one  of  the 
largest  charity  institutions  in  the  country  were  compelled  to  resign,  because  the 
in-and-out  register  revealed  the  fact  that  they  had  not  been  attending  to  their 
duties. 

The  intern  registry  is  an  extremely  important  affair,  and  serves  one  of  the  best 
disciplinary  purposes  that  can  be  imagined.  Young  men  are  very  much  disposed 
to  stay  out  late  at  night,  with  the  result  that  their  work  next  day  will  suffer.  If 
there  is  a  rule  of  the  service  naming  the  hour  at  which  they  must  be  in  the  institu- 
tion, the  registry  book  will  aid  in  the  enforcement  of  that  rule.  A  specially  ruled 
year-book,  with  a  page  for  each  day  in  the  year,  is  best  for  this  purpose.  Such 
books  as  that  can  be  bought  or  easily  made,  or  an  ordinary  diary  can  be  properly 
ruled  for  it,  affording  a  space  for  the  name  of  the  intern  going  out  and  other  spaces 
as  follows: 

"Who  Answers,"  "Emergency  Telephone  Number,"  "Time  Out,"  "Will  Return," 
"Returned."  This  means  that  when  the  intern  goes  out  he  signs  his  own  name  and 
that  of  his  colleague  who  will  answer  for  him  during  his  absence;  the  emergency 
telephone  is  the  number  at  which  he  may  be  found  during  his  absence  in  case  of 
an  emergency;  the  time  out  and  the  time  he  proposes  to  return  are  obviously 
necessary,  and  the  actual  time  of  return  is  indicated  in  the  last  space  when  he  comes 
home.  Upon  the  discipline  of  the  institution  will  depend  the  usefulness  or  other- 
wise of  this  registry. 

There  are  certain  other  people  who  may  also  be  regulated  in  their  goings  and 
comings  by  this  book,  such,  for  instance,  as  the  expert  employees  who  do  not  live 
in  the  institution,  as  the  £-ray  operator,  the  experts  in  the  departments  of  hydro- 
therapy, pharmacy,  laboratory  of  pathology,  milk  station,  and  diet  kitchen. 

THE  CONDITION  BOOK 

There  must,  of  necessity,  be  many  telephone  inquiries  about  the  condition  of 
patients  in  a  hospital,  and  it  is  manifestly  impossible  for  the  switchboard  operator 
to  answer  these  inquiries  intelligently,  and  it  is  equally  impossible  for  her  to  call 
either  the  house  physicians  or  the  nurses  to  the  telephone  to  answer  such  numerous 
inquiries.     Generally  speaking,  in  most  institutions  the  information  given  out  by 


Hi  SINESS    VI  \\  IGEMENT 


.-,(11 


ling  and  unsatisfa 


the  hospital  on  inquiry  of  the  friends  of  patients  is  misli 
and  sometimes  so  untrue  tliat   greal    harm  is 
done. 

The  Michael  Reese  Hospital  has  devised 
what  is  called  a  "Condition  Book."  This  book 
is  made  up  of  loose  leaves  that  can  be  pul  in  or 
taken  out  just  as  in  any  loose-leaf  ledger,  and 
headed  as  follows: 

The  pages  are  11  by  14  inches  in  size,  and 
it  is  ruled  and  cross-ruled,  there  being  eleven 
spaces.  The  first  space,  2  inches  in  width,  is 
for  the  name  of  the  patient.  Each  of  the  other 
spaces  is  'J-inch  wide,  and  the  wording  of  each  of 
these  spaces  in  the  order  of  its  occurrence  from 
left  to  right  is  as  follows: 

"Location";  "Good  night";  "Poor  night"; 
"Better";  "Not  so  well";  "To  be  operated  to- 
day"; "Operated  yesterday";  "Seriously  ill"; 
"Not  seriously   ill";  "Refer  to  head  nurse." 

The  method  of  procedure  with  this  condi- 
tion book  is  as  follows:  There  is  a  book  for 
each  section  of  the  hospital;  the  night  clerk  or 
his  assistant  writes  the  name  of  each  new  patient, 
entered  during  the  day,  inserting  a  new  page 
for  the  purpose  when  necessary.  He  chaws  a 
line  through  the  name  of  each  patient  dis- 
charged during  the  day.  These  books  are  dis- 
tributed to  the  desks  of  the  head  nurses  at 
7:30  o'clock  in  the  morning,  and  it  is  the  last 
duty  of  the  night  head  nurse  of  each  section 
before  going  off  duty  to  check  these  condition 
books,  making  a  proper  check  against  the  name 
of  each  patient  under  her  charge.  These  check- 
marks are  made  lightly  with  a  lead  pencil  so 
that  the  marks  can  be  easily  rubbed  out  with  an 
eraser,  leaving  blank  spaces  for  the  next  day. 

It  was  intended,  when  this  system  was  in- 
stalled, to  have  the  conditions  checked  twice 
daily,  in  the  morning  by  the  night  nurse,  and 
in  the  evening  by  the  day  nurse.  It  has  been 
found,  however,  that  the  evening  checking  is 
rendered  unnecessary  by  the  fact  that  there  are 
not  very  many  inquiries  late  in  the  evening  and 
at  night,  excepting  in  very  serious  cases,  and 
all  these  serious  cases  are  uotilied   to  theswitch- 

board  operator  by  the  head  nurses  on  a  sheet  of 

paper  headed  "emergency  conditions." 

This  book  has  very  greatly  simplified  the 
difficulties  of  answering  inquiries  aboul  patients. 

It  is  a  very  simple  affair,  and  the  work  of  keeping  it  up  i-  so  inconsequential 
matter  of  both  time  ami  labor  thai  it^  use  has  been  more  than  justified. 


1 

i 

2? 

I? 

to" 
'1 

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O 

o 

a 

J? 

O 
ES 

cr 
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o 

lit 

"I 

^; 

in  the 


502 


OPERATION    OF    THE    HOSPITAL 


CALLING  INTERNS  FOR  ATTENDING  PHYSICIANS 


In  addition  to  the  service  of  the  interns'  lighting  system,  described  in  the  sec- 
tions on  Architecture,  these  lights  have  an  exceedingly  useful  office  which  might  well 
be  alluded  to  here.  One  of  the  most  annoying  things  that  physicians  practising 
in  hospitals  have  to  contend  with  is  inability  to  obtain  the  services  of  an  intern 
when  they  visit  their  patients. 

In  the  Michael  Reese  Hospital  it  is  the  custom  for  the  usher  at  the  door  to 
announce  to  the  switchboard  operator  the  presence  of  an  attending  physician  as 
soon  as  he  alights  from  his  vehicle.  The  operator  thereupon  flashes  the  light  of 
the  proper  intern,  and,  if  the  intern  makes  prompt  inquiry  over  some  telephone 
near  which  he  happens  to  be,  he  can  meet  the  attending  physician  either  in  the 
corridor  downstairs  or  at  the  bedside  of  the  patient  whom  he  knows  the  attending 
physician  is  about  to  visit.      The  promptness  or  otherwise  of  this  service  will 


^m  '  jf,   .   ,   .  J.j*         ■  -   m  .  I  V  ?■    < 


Fig.  175. — Office  key-board. 

depend  wholly  upon  the  discipline  in  the  institution,  and  upon  the  enforcement 
of  rules  requiring  the  prompt  answer  of  interns  to  all  their  lights. 

Naturally,  if  it  is  the  policy  of  the  institution  to  cater  to  the  wants  of  and  to 
save  time  for  attending  physicians,  this  policy  can  be  best  met  by  giving  these  men 
the  prompt  attendance  of  their  interns  when  they  enter  the  institution  doors. 
There  is  hardly  anything  more  unsatisfactory  to  an  attending  physician  than 
to  have  to  visit  his  patient  unattended,  and  without  the  presence  of  the  intern  on 
whom  he  must  eventually  rely  for  the  carrying  out  of  his  orders,  and  not  only  for 
the  carrying  out  of  orders,  but  in  order  that  he  may  advise  the  intern  as  to  the 
possibilities  in  the  case,  of  possible  emergency,  for  instance,  and  what  he  shall  do 
in  case  it  occurs. 

THE  OFFICE  KEY-BOARD 

In  every  hospital  there  are  many  rooms  that  must  be  kept  locked  securely, 
with  the  key  in  the  hands  of  some  trusted  head  of  a  department.    Often  the  office 


BUSINESS   MANAGEMENT  503 

may  have  to  get  into  one  of  these  rooms  in  the  absence  of  the  regular  custodian. 
The  attendant  may  also  lose  his  key.  It  is  well,  in  fact  necessary,  for  the  office  to 
have  duplicate  keys  to  every  locked  room  in  the  house.  Figure  175  shows  a  key- 
hoard  to  meet  this  phase  of  administration.  It  is  merely  a  cabinet  of  wood,  1  inch 
deep,  lined  with  green  baize  or  plush,  with  a  lid  of  same  size,  shape,  and  finish,  pro- 
vided with  lock  and  key.  Each  hook  is  numbered,  and  there  is  an  index-book  hung 
from  one  of  the  hooks.    It  is  a  most  satisfactory  detail  of  hospital  management. 

REPAIRS  EN  THE  HOSPITAL 

The  question  of  who  shall  handle  the  expert  help  in  the  hospital  depends  on 
individual  conditions.  In  large  institutions,  where  there  is  a  competent  chief 
engineer,  who  can  supervise  the  plumber,  gas  and  steamfitter,  and  electrician, 

MICHAEL  REESE  HOSPITAL 


REQUISITION  FOR  REPAIRS 


To  the  Superintendent: 

Please  furnish  the  following  Repairs 


(Git*  ei»rt  loeauoo) 


-Department. 


- Head  of  Dept. 

Approved — 

Began Finished Hours 


Material  used- 


By- 


Fig.  170. — Requisition  for  repairs. 

and  where  there  is  a  master  mechanic  to  superintend  the  work  of  the  carpenters 
painters,  glaziers,  and  plasterers,  the  problem  settles  itself. 

In  small  hospitals  the  housekeeper  may  have  to  <lo  nil  the  supervising,  give  out 
the  work,  decide  how  things  shall  be  done  and  when. 


504  OPERATION    OF    THE    HOSPITAL 

But,  however  the  personnel  and  direction  of  things  are  arranged,  there  are  many 
repairs  to  do,  and  unless  there  is  a  definite  system  about  it  there  will  be  much  waste 
of  time  and  much  lost  material.  An  excellent  way  is  to  have  all  orders  for  repairs 
made  out  in  writing,  and  have  these  written  orders  pass  through  the  office  of  the 
superintendent.  Figure  176  shows  a  good  form  for  repair  orders.  This  blank 
fixes  the  exact  locality,  signed  by  the  person  who  knows  about  what  is  wanted, 
contains  a  space  for  the  approval  of  the  superintendent,  and  at  the  bottom  has 
space  for  the  time  employed  and  the  material  used,  these  facts  to  be  signed  by  the 
mechanic  who  does  the  work. 

DISPOSITION  OF  THE  DEAD 

The  death  of  a  patient  in  the  hospital  sets  moving  as  definite  a  technic  as  any 
other  professional  or  scientific  incident  in  the  institution's  life.  Especially  is  this 
true  in  communities  where  constituted  health  authorities,  either  national,  state,  or 
municipal,  are  in  control  of  the  people's  health  and  hygiene,  and  there  are  certain 
exactions  under  these  conditions.  The  first  thing  to  determine  is  whether  the 
death  has  come  from  natural  causes,  and  whether  the  patient  may  be  buried  in  the 
regular  course  of  events.  In  most  large  cities  hospitals  are  required  to  certify  to 
the  coroner  any  case  that  dies  within  a  specified  time,  usually  twenty-four  hours 
after  the  patient  entered  the  institution.  This  does  not  mean  necessarily  that  the 
case  is  one  for  the  coroner's  inquiry,  but  rather  one  for  the  coroner's  discretion. 
Many  of  these  patients  who  die  so  soon  after  reaching  the  hospital  have  been  at- 
tended at  their  homes  by  the  same  physician  who  attends  them  to  the  end,  and 
the  cause  of  death  would  be  quite  as  plain  as  though  the  case  had  remained  at 
home,  and  the  coroner  in  such  a  case  would  inevitably  refuse  to  act  and  the  death 
certificate  would  be  certified  to  the  health  department  in  the  ordinary  way.  In 
small  communities,  where  the  constituted  authorities  make  no  such  requirement  as 
this,  it  is  an  excellent  safeguard  for  institutions,  and  prompts  them  to  be  over- 
careful  about  certifying  the  death  of  patients.  The  reputation  of  many  a  fine  medi- 
cal man,  hitherto  spotless,  has  been  sadly  damaged  by  some  innuendo  or  charge 
brought  by  friends  of  a  deceased  patient  touching  the  physician's  handling  of  the 
case,  and  sometimes  such  charges  are  made  too  late  to  be  counteracted  by  an 
inquiry,  as,  for  instance,  the  patient  may  have  been  buried;  and  it  seems  to  be  a 
favorite  amusement  in  some  rural  localities  for  the  good  people  to  gossip  about 
causes  of  death  in  their  midst,  and  even  an  institution  can  be  badly  smirched  in  its 
reputation  for  hurriedly  certifying  to  the  death  of  a  patient. 

In  very  well-conducted  hospitals  it  is  the  rule  for  some  one  in  authority,  not  the 
physician  in  the  case  or  an  intern  or  a  nurse,  but  some  one  connected  with  the 
administration  of  the  institution,  to  see  the  friends  of  the  dead  on  the  pretense,  per- 
haps, of  sympathizing  with  them,  but  in  reality  for  the  purpose  of  sounding  the 
frame  of  mind  in  which  the  people  are  left  by  their  bereavement.  At  such  a  moment 
it  is  beyond  human  nature  to  contain  one's  self  if  there  is  even  a  lurking  suspicion 
that  something  was  not  as  it  should  have  been,  and  a  keen  officer  will  find  in  a 
moment  whether  there  is  any  reason  why  a  certificate  of  death  should  not  be 
issued.  This  interview  has  two  purposes,  the  one  just  mentioned  and  the  further 
one  of  offering  aid  and  assistance  to  the  bereaved  family.  With  hospital  people 
death  is  an  every-day  occurrence,  but  in  private  homes  it  is  usually  rare  that  the 
people  have  to  superintend  the  arrangements  for  taking  care  of  the  dead  and  for 
funerals,  and  usually  the  friends  of  a  patient  will  want  advice  about  their  conduct 
of  affairs,  and  the  administrator  of  the  hospital  can  help  to  this  end  and  the  people 
will  be  grateful  for  his  aid. 


BUSINESS   MANAGEMENT  505 

But  supposing  the  patient  has  died  within  a  few  hours  after  reaching  the 
hospital,  and  there  had  been  no  antecedent  medical  attention  of  record;  in  such  a 
case  the  hospital  would  be  remiss  not  to  notify  the  coroner  at  once,  and  this  would 
be  the  case  whether  the  institution  is  a  large  metropolitan  hospital  or  a  smaller 
institution  in  the  country,  anil  it  will  then  lie  with  the  coroner  whether  an  oflicial 
inquiry  shall  he  made  or  whether  the  institution  shall  be  ordered  to  proceed  in  the 
usual  way,  assuming  the  death  to  have  been  due  to  natural  cause.  But,  in  any 
event,  the  institution  has  taken  the  initiative  to  call  the  attention  of  the  coroner 
to  the  case,  and  no  possible  subsequent  inquiry  can  place  the  institution  at  a  dis- 
advantage. 

Let  us  now  suppose  another  condition  of  affairs:  Let  us  say  the  patient  had  been 
in  the  hospital  for  days,  or  even  weeks,  and  that  death  had  been  expected  and  had 
not  come  as  a  surprise,  but  when  it  did  finally  come  the  family  began  to  talk  of 
incidents  in  the  case  and  complain  of  neglect  of  the  patient,  either  on  the  pari  of 
the  attending  physician,  interns,  nurses,  or  institution  authorities;  it  may  bethal 
these  complaints  are  a  natural  expression  of  grief;  but  the  institution  owes  it  to 
itself  to  suggest  to  the  family  of  the  deceased  that  the  authorities  of  the  hospital  are 
quite  as  anxious  to  know  if  there  had  been  any  neglect  as  the  patient's  family  could 
be,  and  that,  therefore,  there  should  be  an  official  inquiry  into  the  conduct  of  the  case, 
and  to  that  end  the  coroner  would  be  notified.  Oftentimes  a  proposal  of  this  sort 
will  bring  the  family  to  its  senses,  and  bring  a  retraction  of  any  innuendoes  or 
charges  that  had  been  made.  But,  on  the  other  hand,  sometimes  the  family  are 
agreeable  to  such  an  inquiry,  and  in  either  event  the  hospital  has  protected  itself 
and  prevented  any  subsequent  scandal  from  any  quarter  concerning  either  the 
conduct  of  the  case  or  its  disposition  after  the  death  of  the  patient. 

The  certificate  of  death  when  called  for  is  usually  in  a  form  prescribed  by  the 
local  authorities,  and  in  the  large  communities  it  has  grown  to  be  a  very  burden- 
some official  paper,  oftentimes  impossible  to  fill  out  to  the  satisfaction  of  the 
authorities,  as,  for  instance,  requirement  is  now  made  in  some  cities  for  a  history 
of  the  family  for  two  or  three  generations  back,  and  while  such  data  may  be  of 
intense  interest  it  oftentimes  requires  the  summoning  of  distant  members  of  the 
family,  and  delay  of  days  while  the  certificate  is  held  up  and  the  obsequies  neces- 
sarily postponed.  In  some  communities  the  certificate  of  death  swings  to  the  other 
extreme,  and  is  a  very  lax  and  meager  affair,  containing  hardly  any  information, 
which  will  render  the  statistics  of  that  community  wholly  worthless  from  the 
standpoint  of  the  United  States  census  in  the  department  of  vital  statistics  of  the 
governmental  organization,  and  these  statistics  are  extremely  valuable. 

When  a  body  is  to  be  buried  in  the  community  in  which  the  patient  dies  thi 
original  certificate  of  death  is  all  that  is  required,  and  where  a  body  is  to  be  trans- 
ported from  one  place  to  another,  and  especially  from  one  state  to  another,  the 
federal  laws  come  into  play,  and  require  that  the  body  shall  be  embalmed  in  some 
prescribed  way  and  sealed  in  a  properly  constructed  casket,  and  in  some  such  cases 
very  strict  requirement  is  made  for  a  certificate  setting  out  the  exact  cause  of 
death,  with  the  intent,  to  prevent  the  transportation  of  bodies  dead  of  some  com- 
municable disease. 

Effects  of  the  Dead. — There  are  two  classes  of  effects  of  the  dead— the  valuables, 
if  there  are  any,  in  possession  of  the  hospital  business  office,  tinder  a  receipt  held  b\ 
the  patient  or  by  the  head  nurse  for  him,  and  the  clothing  and  wearing  apparel. 
"When  a  patient  dies  it  sometimes  becomes  a  matter  of  concern  a-  to  the  disposition 

of  these  effects,  and  too  frequently  there  is  a  contention  between  relatives  or 
friends  as  to  who  shall  take  possession  of  them.     This  contention  will  rarely  come 


506  OPERATION    OF   THE    HOSPITAL 

if  there  is  a  husband  or  wife,  children  or  parents  of  the  deceased,  and  in  such 
cases  it  will  never  be  questioned  if  the  effects  are  turned  over  to  such  close  relatives; 
but  oftentimes  the  patient  has  no  immediate  family,  and  the  institution  should  then 
be  extremely  careful  not  to  lose  possession  of  valuables  that  it  may  be  called  upon 
to  produce  to  an  executor  or  administrator,  and  it  is  far  better  to  simply  hold  the 
effects  in  such  a  case,  with  the  explanation  that  the  institution  prefers  to  await 
whatever  legal  proceeding  there  may  be  of  a  probate  character,  and  to  turn  the 
effects  over  to  the  legal  representative.  There  will  hardly  ever  come  a  question  as 
to  the  dignity  of  this  position,  and  even  in  the  fiercest  contest  for  possession  of  a 
patient's  effects  there  will  come  no  criticism  of  the  institution  if  it  takes  this  ground. 
Sometimes  the  patient  has  been  brought  to  the  institution  by  the  police,  and  the 
police  will  have  taken  a  receipt  for  whatever  effects  the  patient  may  have  had,  and 
then,  of  course,  the  police  can,  after  the  death  of  the  patient,  take  possession  of  these 
effects  by  producing  their  receipt,  and,  as  law  officers,  the  police  will  be  entirely 
responsible  custodians,  and  the  institution  will  be  protected  in  giving  up  the 
valuables.  The  same  condition  will  sometimes  exist  in  coroner's  cases,  where  the 
police  have  brought  in  an  accident  case  and  the  patient  has  died.  It  has  happened 
occasionally  that  the  coroner  has  demanded  possession  of  the  effects  of  the  dead, 
and  the  institution  can  then  either  produce  the  effects  themselves  and  turn  them 
over  to  the  coroner,  taking  his  receipt  therefor,  item  by  item,  or  it  can  turn  over 
whatever  receipt  it  holds  for  the  property  that  has  been  surrendered  to  the  police, 
and  then  the  two  legal  departments  can  fight  it  out  among  themselves. 

Papers  to  Certify. — It  becomes  the  duty  of  the  hospital,  in  the  ordinary  course 
of  business  connected  with  the  death  of  a  patient,  to  certify  the- death  in  connec- 
tion with  insurance  papers,  and  usually  this  is  a  routine  matter,  but  there  are  occa- 
sions in  which  it  becomes  a  delicate  question  just  what  to  do.  A  great  many 
foreigners  in  this  country  patronize  the  industrial  insurance  companies,  and  it  is 
often  a  habit  of  these  transplanted  people  to  get  themselves  insured  almost  as  soon 
as  they  arrive  in  this  country.  Moreover,  it  very  often  happens  that  these  people, 
after  they  have  been  here  for  a  time,  conclude  to  change  their  names,  for  purposes  of 
euphony  or  for  business  reasons.  The  standards  of  these  transplanted  people, 
especially  the  lower  classes,  are  not  quite  the  same  as  those  that  prevail  in  this 
country  among  the  better-to-do  classes  of  people,  and  they  think  it  is  quite  in  line 
with  ordinary  business  for  them  to  change  their  age  as  well  as  their  names,  and 
usually,  when  this  is  done,  the  age  given  to  the  insurance  company  will  be  very 
much  younger  than  the  patient  really  is,  because  the  premium  will  be  less.  Such 
a  patient  may  remain  in  good  health  for  several  years  perhaps,  and  all  of  a  sudden 
become  ill  and  seek  admission  to  a  hospital.  He  forgets  all  about  his  insurance 
policy,  and  gives  his  Americanized  name  and  his  real  age.  When  such  a  patient 
dies  it  leaves  his  beneficiary  in  quite  a  dilemma.  Naturally,  the  identity  of  the 
patient  is  at  issue  in  the  first  place,  and  this  has  to  be  settled;  then  it  transpires 
that  the  patient  obtained  the  policy  by  false  representation — that  is,  by  giving  the 
wrong  age — and  the  insurance  company,  if  so  disposed,  can  easily  set  up  the 
charge  of  fraud  in  such  a  case. 

As  a  rule,  this  is  not  done,  however,  and  the  industrial  insurance  companies  of 
the  day  have  recognized  that  this  form  of  deception  is  not  really  deception  in  the 
broader  sense,  but  due  rather  to  ignorance  on  the  part  of  the  insured  concerning 
American  methods  of  doing  things,  and  usually  such  insurance  policies  have  been 
paid  on  a  certificate  from  responsible  people  concerning  the  identity  of  the  insured; 
and  then,  concerning  the  age,  they  have  usually  figured  the  patient  at  his  correct 
age,  and  deducted  from  the  insurance  policy  such  amount  as  the  patient  would  have 


BUSINESS  MANAGEMENT  5<)7 

been  compelled  to  pay  in  the  shape  of  premiums  if  he  had  given  his  correcl  age. 
Bui  there  is  always  a  great  deal  of  tangle  under  circumstances  such  as  these,  and  it 

has  taken  time  and  often  a  good  deal  of  work  to  straighten  the  affair  out.  So 
that  in  a  good  many  institutions,  where  considerable  numbers  of  foreigners  are 
cared  for,  it  has  become  a  definite  part  of  the  admission  technic  of  the  institution 
to  make  inquiry  concerning  insurance,  the  change  of  names,  possibility  that  the  age 
given  at  the  hospital  may  not  be  in  accordance  with  the  age  given  to  the  insurance 
company,  and  so  on.  It  is  true  these  inquiries  sometimes  frighten  patients,  and 
they  begin  to  think  about  the  possibility  of  death,  but  they  always  save  the  insti- 
tution a  great  deal  of  unnecessary  labor  and  embarrassment,  and  sometimes  vastly 
simplify  the  business  between  the  patient's  relatives  and  the  insurance  companies; 
thus  it  would  seem  to  be  justified. 

It  goes  without  saying  that  the  institution  will  never  be  justified  in  making 
false  statements,  either  for  the  benefit  of  patients  or  their  families,  on  behalf  of 
an  insurance  company,  either  as  to  the  cause  of  death  or  the  age  or  name  of  the 
deceased. 

How  to  Obtain  Autopsies. — Nearly  everyr  state  in  the  American  Union  forbids 
the  making  of  a  postmortem  examination  of  a  body,  except  with  the  consent  of 
the  relatives  of  the  dead.  This  law  is  in  consonance  with  a  widespread,  almost 
universal,  public  sentiment  against  what  many  people  are  accustomed  to  call  the 
desecration  of  the  dead,  and  the  public  at  large  assumes  the  mistaken  attitude  that 
the  holding  of  a  postmortem  is  merely  to  satisfy  an  idle  curiosity  of  the  physician 
who  attended  the  patient,  and  merely  to  assure  him  whether  he  had  guessed  cor- 
rectly at  the  nature  of  the  patient's  illness.  It  is  useless  to  protest  to  the  relatives 
of  the  dead  that  this  attitude  is  not  a  correct  one;  that  the  physician  does  not  want 
to  satisfy  an  idle  curiosity;  that  his  prime  object  is  to  identify  certain  antemortem 
manifestations  with  the  actual  condition  of  the  patient  as  revealed  in  the  post- 
mortem examination,  to  the  end  that  the  information  he  secures  in  this  way  may 
be  utilized  in  the  future  in  the  interest  of  the  living. 

"While  it  is  wholly  improper  to  recommend  the  actual  deception  of  the  relatives 
of  the  dead  in  order  to  obtain  a  postmortem,  it  is  sometimes  justifiable  to  use 
collateral  arguments,  especially  when,  as  in  this  case,  they  have  for  their  object  a 
sound,  just,  and  virtuous  puqx>se.  Therefore,  the  wits  of  hospital  administrators 
have  evolved  certain  plausible  propositions  likely  to  result,  one  way  or  another, 
in  obtaining  the  desired  postmortem  inquiry. 

If  it  is  a  child  that  has  died,  and  there  are  other  children  in  the  family,  it  would 
seem  not  wholly  an  ignoble  argument  to  call  the  attention  of  the  parents  to  the 
fact  that  the  child  might  have  had  something  the  matter  with  it  that  partook  of 
the  nature  of  an  inherited  or  family  weakness,  and  that  a  revelation  of  the  exact 
conditions  might  be  of  immense  value  at  some  time  in  the  future  when  another  child 
should  be  ill. 

Then,  again,  there  is  the  insurance  feature,  especially  in  case  of  the  adult. 
Many  insurance  companies  have  clauses  in  their  policies  that  are  in  the  nature  of 
"catch  questions,"  and  it  not  infrequently  happens  thai  the  diagnosis  of  a  case 
may  develop  a  refusal  on  the  part  of  the  insurance  company  to  pay  the  policy  because 

of  apparent  misrepresentations  by  the  insured  in  regard  to  his  physical  condition 
at  the  time  of  insurance  or  in  regard  to  his  family  history.  It  may  be  admitted  that 
the  refusal  of  insurance  companies  to  pay  policies  for  technical  violations  of  the 

policy  are  le>>  frequent    than  formerly,   hut    they  do  exist,  and   this  argument    will 

sometimes  be  a  potent  one  to  secure  a  postmortem  inquiry  where  it  i.-  actually 

justified. 


508  OPERATION    OF   THE    HOSPITAL 

Then,  too,  if  the  deceased  be  an  adult  and  the  parent  of  a  family,  the  offspring 
have  a  right  to  an  absolute  knowledge  of  the  disease  from  which  the  parent  died. 
They  may  not  claim  that  right,  and  rarely  do  so  out  of  sentiment  coincident  with 
their  grief,  but  the  family  physician  must  think  for  them,  and  he  has  a  right  to  this 
information,  and  it  is  his  duty  to  urge  this  right  out  of  consideration  for  the  health 
and  future  welfare  of  the  offspring. 

In  isolated  cases  there  are,  of  course,  many  other  arguments  that  may  be  used 
with  all  propriety  to  secure  a  postmortem  examination  in  a  case  that  has  been  of 
sufficient  interest  and  perplexity  to  raise  a  question  of  the  diagnosis. 

AMBULANCE  SERVICE 

In  the  Eastern  hospitals,  especially  in  the  large  cities,  an  ambulance  service 
seems  to  be  a  recognized  and  uniform  necessity.  In  the  west  and  central  west  of  this 
country  nearly  all  private  hospitals — that  is,  those  institutions  that  cater  to  private 
pay  patients  only — find  it  convenient  and  profitable  to  maintain  an  ambulance 
service,  not  only  because  they  obtain  a  profitable  fee  for  each  patient  they  haul, 
but  because  oftentimes  such  an  institution  may  secure  a  profitable  private  patient 
because  it  has  an  ambulance  immediately  ready  to  transport  the  patient  to  the 
hospital  when  the  call  comes. 

This  question  of  ambulance  service  is  rather  a  mixed  problem,  and  in  many  local- 
ities is  a  perplexing  and  important  one.  In  some  of  the  large  eastern  cities,  where 
semiprivate  institutions  have  definite  arrangements  with  the  city,  county,  or 
state  for  taking  care  of  free  patients  under  some  per  capita  method,  an  ambulance 
is  not  a  distinct  drain  upon  the  resources  of  the  institution,  because,  even  for  free 
patients,  the  hospital  is  paid  a  moderate  fee  for  the  work  of  its  ambulance,  and  the 
question  whether  or  not  an  institution  shall  maintain  an  ambulance  can  be  easily 
settled  on  a  basis  of  the  individual  case.  But  there  are  other  institutions  that 
receive  and  take  care  of  a  large  percentage  of  free  patients  Avithout  any  pay  what- 
ever from  any  source,  where  the  keeping  of  an  ambulance  would  mean  a  distinct 
hardship  and  would  mean  no  income  whatever. 

Let  us  take,  for  instance,  the  Michael  Reese  Hospital  in  Chicago  as  a  case  in 
point:  more  than  60  per  cent,  of  the  patients  of  that  institution  are  absolutely 
free  patients,  and  the  funds  which  support  that  institution  are  contributed  by  nearly 
4000  citizens  of  Chicago.  Many  of  these  people  make  very  large  contribu- 
tions, up  into  the  thousands  of  dollars  annually.  Many  of  these  wealthy  citi- 
zens are  in  touch  with  large  masses  of  very  poor  people,  who  are  in  many  cases  de- 
pendent more  or  less  upon  them.  The  institution  also  has  for  its  patients  some  of 
the  wealthiest  and  most  aristocratic  citizens  of  the  community. 

The  wealthy  contributors  to  the  funds  of  the  hospital  regard  the  institution  as 
distinctly  a  charitable  one,  which  it  is,  and  if  the  institution  maintained  its  own 
ambulance  service  these  wealthy  patrons  would  feel  that  it  was  the  duty  of  the 
institution  to  haul  the  free  patients  to  the  hospital  whenever  called  upon  by  a  large 
contributor  or  by  a  responsible  citizen  to  do  so.  Most  of  the  free  patients  of  the 
institution  live  in  the  poorer  quarter  of  the  city,  several  miles  away,  and  the 
admission  of  these  free  patients  amounts  to  from  ten  to  twenty  per  day.  It  is  a 
certainty  that  if  the  institution  maintained  its  own  ambulance  service,  two  or  more 
vehicles  would  be  required  to  haul  the  free  patients  alone,  and  the  contributors 
to  the  hospital  would  insist,  and  justly  so,  that  these  free  patients  should  have  the 
first  call  on  the  ambulance  service,  so  it  would  naturally  transpire  that  the  insti- 
tution vehicles  would  be  constantly  employed  in  the  hauling  of  free  patients,  and 


I!  i  SINESS    M  US  IGEMENT  509 

the  greater  number  of  ambulances  ii  had  the  greater  would  be  the  call  fur  this  free 
service,  and  it  would  follow,  of  course,  that  mosl  of  the  time,  when  the  institution 
bad  an  opportunity  to  haul  a  patient  who  could  afford  to  pay  for  the  service,  it- 

ambulances  would  he  out  on  a  free  call,  and  s e  private  ambulance  would  bave 

to  be  employed  and  thai  profitable  business  lost  to  the  hospital. 

Therefore,  the  institution  which  never  refuses  to  accept  a  free  patient  that  can 
he  properly  admitted  has  wisely  taken  the  broad  ground  that,  if  it  undertakes  to 
care  for  all  applicants  for  free  service,  it  is  little  enough  to  ask  that  those  free  patient  - 
he  at  least  delivered  to  the  hospital  without  cost  to  the  institution. 

Perhaps  this  illustration  may  seem  personal  under  the  circumstances,  hut  it 
seems  to  state  the  case  of  a  certain  phase  of  ambulance  service  so  aptly  that  it 
seemed  pardonable  to  employ  it. 

Ambulance  service  is  a  costly  business.  Let  us  take  the  horse  vehicle  first,  for 
instance.  If  the  hauls  are  very  short,  and  the  patronage  of  the  institution  small, 
and  the  ambulance  maintained  more  for  parade  purposes  than  actual  use,  one  team 
of  horses  and  one  shift  of  ambulance  men  will  answer  all  puqioses,  because  oighl 
hauls,  under  such  circumstances,  would  be  so  infrequent  that  the  same  horse-  and 
the  same  men  could  do  the  work;  but  where  the  hauling  would  be  over  great  dis- 
tances, especially  in  the  rough  streets  of  the  average  large  city,  and  where  the 
business  is  great,  two  complete  shifts  of  horses  and  men  will  be  required  for  each 
vehicle. 

A  fairly  good  horse  ambulance  can  be  purchased  for  about  $600  or  S800. 
Horses  at  once  serviceable  and  of  good  appearance  will  cost  at  least  $400  per 
pair,  and,  if  the  institution  is  lucky  in  its  horses  and  drivers,  a  good  team  of  horses, 
working  on  a  twelve-hour  shift,  hitched  to  a  busy  ambulance,  will  last  a  year  or 
two,  when  they  will  have  to  be  renewed.  Repairs  on  the  ambulance  will  perhaps 
not  be  more  than  §100,  or  at  most  $200,  per  year  while  the  vehicle  is  compara- 
tively new,  but  an  ambulance  will  not  stand  hard  usage  on  the  rough  streets  of  a 
large  city  and  remain  in  presentable  shape  for  more  than  four  or  five  years. 

Ambulance  men,  of  which  there  must  be  two  for  each  shift,  will  cost  about  $75 
per  month  each,  including  their  board.  So,  if  we  sum  up  the  actual  expense  inci- 
dent to  the  maintenance  of  a  horse  ambulance,  with  a  double  shift  of  men  and 
horses,  we  can  figure  about  as  follows: 

Ambulance  cost  and  repairs,  about S  200  per  year. 

Horses,  renewals,  about 400 

Four  men,  at  S900  per  year  each 3000 

or  a  total  of  about  $4200  for  annual  maintenance. 

The  item  of  $3600  for  men  to  man  the  ambulance  seems  an  exorbitant  amount, 
and,  without  question,  men  can  be  employed  for  a  good  deal  less  money,  but  it 
requires  intelligence  and  care  ami  experience  and  a  good  deal  of  technical  knowl- 
edge to  handle  sick  people  on  a  stretcher,  and  especially  to  take  them  out  of  the 
average  apartment  building  and  down  the  usual  winding  stairs,  and  to  put  them  in 
the  ambulance  so  that  they  will  ride  comfortably  and  without  untoward  results 
from  the  trip,  and  cheap  men  are  not  a  paying  investment  for  such  purposes. 

Now  let  us  consider,  very  briefly,  the  automobile  ambulance:  A  first-rate  auto- 
mobile ambulance,  built  to  travel  the  heavy  streets  of  a  large  city  and  to  go  in  all 
kinds  of  weather,  cost-  between  $3000  and  $4000,  and  the  greater  the  initial  cosl 
the  longer  it  is  likely  to  iast.  Automobile  ambulances  have  not  been  in  regular  ser- 
vice anywhere  long  enough  to  justify  any  accurate  figures  a-  to  the  life  of  the  vehicle 

employed  for  ambulance  purposes,  but  we  have  a  fair  guide  in  the  average  auto- 


510  OPERATION    OF   THE    HOSPITAL 

mobile  used  by  the  busy  medical  practitioner.  His  automobile  will  cost  less,  it 
is  true,  perhaps  not  more  than  $2000  on  the  average,  and  it  has  a  lifetime  of  about 
four  years,  and  it  would  seem  fair  to  expect  the  automobile  ambulance  to  do  about 
as  well,  which  would  mean  an  annual  cost  in  the  shape  of  purchase  price  of  about 
$1000  per  year,  and  for  maintenance — that  is,  repairs,  including  oil,  gasoline,  and 
new  tires — about  $100  per  month,  or  $1200  per  year;  and  then  we  have  the  same 
ambulance  force  of  men,  with  the  additional  expense  that  at  least  two  of  the  four 
men  must  be  competent  chauffeurs,  giving  us  an  additional  cost  for  operation  of 
$3600,  or  a  total  of  $5800  per  year  for  cost  and  maintenance  of  one  automobile 
ambulance. 

There  is  this  further  detail  concerning  the  operation  of  an  ambulance,  compar- 
ing the  horse  vehicle  with  the  automobile :  in  northern  latitudes,  where  deep  winter 
snows  are  likely  to  prevail,  there  are  many  days  in  the  winter  time  when  an  auto- 
mobile ambulance  cannot  be  used.  Automobile  makers  will  not  concede  this;  it 
is  true,  nevertheless,  that  there  are  many  days  in  the  winter  time  when  an  auto- 
mobile ambulance  cannot  leave  the  garage.  Where  conditions  present  themselves, 
such  as  they  do  in  New  York  or  Chicago,  for  instance,  the  horse  ambulance  can 
travel  every  day  in  the  year.  The  automobile  ambulance,  again,  is  likely  to  break 
down,  and  experience  has  shown  that  it  does  break  down  at  most  inopportune 
times  and  when  human  life  hangs  on  the  integrity  of  the  machine. 

The  horse  ambulance  generally  gets  the  patient  to  the  hospital,  if  not  quite  so 
quickly,  as  a  rule,  at  least  more  surely. 

Taking  these  fundamental  principles,  and  these  rather  conservative  figures 
of  cost  and  maintenance  for  ambulance  service,  the  administrator  of  almost  any 
hospital,  located  anywhere  and  maintained  for  the  care  of  almost  any  kind  of 
patients,  will  be  able  to  answer  the  question  for  himself,  whether  or  not  he  wants 
to  and  can  afford  to  maintain  an  ambulance  service. 

The  foregoing  sections  on  the  business  office  have  to  do  merely  with  the  phys- 
ical acts  that  immediately  concern  the  patient  and  his  admission  to  the  hospital. 
The  further  business  of  the  office  will  be  more  properly  treated  under  the  head  of 
Hospital  Accounting,  and  under  the  other  several  headings  relative  to  the  pur- 
chase, receipt,  and  distribution  of  supplies. 


HOSPITAL  ACCOUNTING 

Hospital  accounting  differs  from  the  bookkeeping  of  most  other  business  enter- 
prises in  that  the  sources  of  income  are  vastly  increased  in  number;  that  many 
of  the  transactions  recur  at  more  frequent  intervals,  such  as  the  operations  of  the 
house  count  and  consequent  readjustment  of  patients'  accounts;  that  many  of  the 
expense  items  are  contingent  and  not  constant;  and  in  the  further  fact  that  the 
accounts  must  be  carried  out  and  finally  summarized  into  statements  and  bills  for 
patrons  and  others  not  versed  in  the  technicalities  of  bookkeeping,  and  for  such 
other  purposes  as  the  vital  statistics.  All  these  conditions,  while  they  do  not 
complicate  or  make  less  accurate  any  good  hospital  accounting  system,  do  require 
details  and  side  entries  not  common  to  most  other  lines  of  business. 

Generally  speaking,  hospital  accounting  is  very  nearly  the  sum  total  of  two 
words,  income  and  expense.  There  are,  of  course,  asset  and  liability  accounts,  but 
the  income  and  expenditure  account  in  the  general  ledger  is  the  hub  upon  which  the 
whole  system  of  maintenance  and  management  revolves. 

Hospital  bookkeeping,  perhaps,  properly  begins  with  the  expenditure  side  of 
the  transaction,  but,  assuming  that  the  institution  is  fully  equipped  with  all  the 
necessary  paraphernalia  for  taking  care  of  the  sick,  and  that  the  reader  has  a 
slight  knowledge  of  double-entry  bookkeeping,  we  will  proceed,  step  by  step, 
eliminating  elaborate  and  complicated  details,  to  tell  the  story  of  a  system  of  account- 
ing that  is  at  once  unique  and  simple,  which  has,  in  actual  experience,  proved  ample 
and  satisfactory.  Let  us  then  begin,  first,  by  taking  up  the  income  side  of  the 
proposition  under  the  general  heading: 

INCOME 

Income  from  Pay  Patients. — The  original  entry  from  which  the  accounting 
system  of  the  institution  depends  for  its  information  regarding  the  pay  patients, 
such  as  time  of  entry,  price  of  room  or  ward,  discharge,  etc.,  is  taken  from  the 
admission  card,  which  is  referred  to  elsewhere,  under  the  section  on  Business 
Management.  Besides  the  revenue  from  rooms  and  wards,  other  sources  of  rev- 
enue from  patients  are:  Undergraduate  nurses'  fees,  board  for  graduate  special 
nurses,  guest  charges,  operating-room  charges,  surgery  and  dispensary  charges, 
x-ray  charges,  telephone,  and  any  sundry  charges  fixed  as  a  system  by  the  board  of 
directors,  including  laboratory,  hydrotherapeutic  department,  drugs,  special  diets, 
and  so  on. 

Accounts  Receivable. — Accounts  due  from  patients  is  the  first  detail  to  be 
considered,  and  this  group,  as  heretofore  tabulated,  when  charged  to  patients, 
is  known  as  "accounts  receivable." 

The  bookkeeper's  first  duty  in  the  morning  is  to  open  up  his  accounts  from  the 
admission  cards,  and  also  note  any  changes  when  patients  have  been  transferred 
to  a  different  room  or  ward,  and  to  close  up  accounts  of  discharged  patients.  The 
changes,  etc..  are  attended  to  by  the  room  clerk,  all  of  which  the  bookkeeper  scru- 
tinizes carefully,  for  the  importance  of  this  is  obvious,  and  an  oversight  in  any  one 
of  these  details  makes  the  work  of  rendering  accounts  a  source  of  annoyance  and 

.-.11 


512 


OPERATION    OF    THE    HOSPITAL 


■*«. 

»«. 

p  ' 

W„d 

a,i™i 

H 

1UU 

Discharged 

t—j™. 

HUrfeM 

"-""» 

*■ 

„ 

.iwa™. 

»vj     •• 

Uh 

-       B^d 

Crf.0,... 

Op^^Ro^ 

XR., 

a^^ra^ 

T<M,m 

« 

**_. 

.  I.w 

1 

Fig.  177. — Patients'  ledger  sheet. 


ofbodpttal 


In  account  with 

em 


Chicago,. 


ROOM  AND  WAHD  CHARGES  PAYABLE  WEEKLY  IN  ADVANCE 


Surgery  and  Disper 


Fig.  178.— Bill-head. 


HOSPITAL    ACCOUNTING 


f,13 


trouble  to  all  concerned.  The  ledger  sheet  is  prepared  with  appropriate  space  for 
the  various  details,  so  that  one  will  almost  mechanically  fall  into  the  correct  path 
when  rendering  accounts. 

A  reproduction  Of  a  very  convenient  patients'  ledger  sheet  is  herewith  shown 
in  Fig.  1  77,  which  will  accommodate  a  period  of  three  weeks,  which  is  more  than  tin- 
average  length  of  time  a  patient  remains.  In  order  to  save  time  in  writing,  both 
the  ledger  sheet  and  hill-head  have  the  items  to  lie  charged  printed  and  tabulated. 
Figure  178  shows  a  bill-head  containing  some  listed  charges  (others  may  be  added). 


HOSPITAL 


IS 


To  the  Superintendent: 


The- 


has  this  day  furnished  on  the  order  of 


-Department 


the  following  articles  service  to  be  charged  to  the  accounts  of 


Head  of  Dept. 


Fig.  179.— Charge  slip. 


The  data  for  all  other  items  to  be  charged  is  furnished  to  the  bookkeeping  depart- 
ment each  morning  by  the  heads  of  the  various  departments.  A  good  form  for 
a  charge  slip  to  be  made  out  by  department  heads  is  shown  in  Fig.  17'.). 

At  the  time  the  patients'  ledger  account  is  made  out  a  smaller  card  is  also  made. 

with  the  date  and  patient's  name  on  it.  for  a  weekly  card  system  "tickler."    To 

illustrate:  A  patient  enters  the  hospital  on  the  lllth;  his  card  is  filed  away  to  mm 

up  on  the  17th;  the  I kkeeper  then  has  all  the  bills  due  for  that  da\  before  him, 

it  being  unnecessary  to  go  through  the  whole  ledger  to  pick  out  the  accounts  which 


514  OPERATION    OF   THE    HOSPITAL 

are  due.  It  is  obvious  that  on  the  17th  these  cards  are  filed  ahead  one  week  after 
being  attended  to. 

If  a  record  of  the  business  sent  in  by  the  various  doctors  is  desired,  another  card, 
headed  with  the  doctor's  name,  can  be  made  out  at  the  same  time.  The  patient's 
name  and  case  number  entered,  the  figures  can  be  supplied  after  the  patient  leaves 
or  at  any  other  convenient  time.  One  card  will  accommodate  the  records  of  many 
patients,  showing  the  income  from  patients  sent  in  by  any  physician.  This  system 
will  be  especially  advantageous  in  the  so-called  "open-door"  hospital,  where  many 
physicians  send  in  a  few  private  patients. 

After  all  bills  for  the  day  are  made  up  the  same  are  entered  in  detail  in  the 
patients'  income  register  or  journal,  in  which  all  income  from  pay  patients  is  entered, 
and  at  the  end  of  the  month  the  totals  of  the  columns  are  made  into  a  journal 
entry,  and  from  there  carried  to  the  ledger  account.  Accounts  receivable  are 
debited,  and  the  various  items  of  income  from  patients  are  credited  as  follows: 

ACCOUNTS   RECEIVABLE,   DR. 

To  Sundries Cr. 

Room  fees. 
Ward  fees. 
Nurses'  fees. 
Guests'  fees. 
Operating-room  fees. 
Surgery  and  dispensary. 
z-Ray  fees. 
Laboratory  fees. 
Hydrotherapeutie  fees. 
Telephone. 
Sundries. 

The  income  register  is  divided  off  into  columns  with  all  of  the  above  headings, 
and  it  is  reproduced  in  Fig.  180  (income  book). 

In  connection  with  the  foregoing  entry  in  the  journal,  it  will  now  become  neces- 
sary to  introduce  two  new  accounts — viz.:  Income  and  Expenditure  Account  and 
Uncollected  Earnings  Account.  The  income  and  expenditure  account  is  about 
the  most  important  account  we  have  to  deal  with  outside  of  the  general  cash 
account.  Referring  to  the  income  and  expenditure  account  in  the  general  ledger, 
all  the  income  is  entered  on  the  debit  side  and  expenditure  on  the  credit  side,  and, 
in  making  up  the  schedule  or  report  for  the  month  of  income  and  expenditures,  the 
difference  of  the  entries  for  the  current  month  in  the  ledger  must  agree  with  the 
excess  of  income  over  the  expenditures,  or  vice  versa,  of  the  report.  The  uncol- 
lected earnings  account,  above  referred  to,  is  the  controlling  account  of  the  patients' 
account  or  accounts  receivable,  together  with  all  income  from  investments.  The 
journal  entry  in  connection  with  the  foregoing  explanation,  in  reference  to  income 
and  expenditure  account  and  uncollected  earnings,  is  as  follows: 

Income  and  Expenditure,  Dr. 

To  Uncollected  Earnings,  Cr. 

Thus  far  we  have  taken  care  of  accrued  earnings  from  patients,  together  with 
'the  proper  entries  controlling  same. 

In  all  well-regulated  hospitals  the  collection  department  is  kept  busy,  and,  of 
course,  has  been  at  work  all  this  time.  Hospitals  are  not  exempt,  any  more  than 
any  other  business  concerns,  when  it  comes  to  slow,  doubtful,  or  bad  accounts. 


HOSP]  1 M.     V.CC01  NTING 


515 


Advance  payments  should  be  the  rule,  if  only  for  tin-  reason  thai  hospitals  are  aol 
money-making  enterprises,  and  their  energy  and  funds  should  not  be  dissipated  in 
collecting  bills.  Should  an  account  become  slow  and  payment  seem  doubtful, 
about  all  that  is  necessary  in  most  cases  is  to  inform  the  parties  thai  the  patienl 
will  be  transferred  to  the  charity  service  unless  the  bill  is  settled,  and  this  warning, 
in  most  cases,  will  be  sufficient.  A  very  useful  adjunct  in  this  connection  is  the 
visitors'  card  rack,  mentioned  elsewhere.  If  the  bookkeeper  desires  to  see  the  rela- 
tive of  a  patient  whose  account  needs  attention  a  memorandum  is  placed  in  the 
pocket  against  the  name,  which  reminds  the  clerk  at  the  visitors'  desk,  and  the  party 
is  told  to  see  the  cashier  in  the  office.  In  this  way  it  is  almost  impossible  for  accounts 
to  become  delinquent  on  account  of  not  being  able  to  get  in  touch  with  the  parties 
interested.     It  is  inhumane  to  worry  a  patient  about  money  matters,  and  relatives 


Hospital             CHARGES 

TO  PA'S 

PATIENTS 

Mor 

lh 

j| 

'9 

.. 

— 

- 

■ 

■ 

,          , 

...'- 

.         , 

...    | 

| 

.uuml 



i 

— - 

— 

— 

-J- 

Fig.  ISO. — Income  book. 

or  friends  who  have  an  interest  in  the  patient  can  do  business  for  him:  this  will 
obviate  running  any  risk  of  injuring  the  sick  person's  chance  of  recovery,  and  will 
keep  the  hospital  on  the  good  side  of  the  physician  who  is  doing  his  besl  to  cure 
the  patient.  A  nervous  person,  sick  and  in  trouble,  who,  by  the  way,  may  be  per- 
ieci  l\  good  for  all  accommodations  received,  who  receives  a  reminder  of  an  unpaid 
bill  will  nearly  always  be  greatly  distressed  and  sometimes  perhaps  permanently 
injured. 

It  is  extremely  poor  practice  to  take  the  doctor'-  guarantees  for  obligations  to 
be  incurred  by  patients.  A  doctor  may  be  an  excellent  practitioner,  but,  as  a  rule. 
he  makes  a  poor  credit  man,  and.  if  it  afterward  develops  that  the  patient  fails  to 
pay,  it  certainly  seems  unjusl  to  tax  the  accounl  againsl  the  doctor. 

Cash  Receipts. — The  simplest  kind  of  a  record  book  is  kepi  to  record  the  receipt- 


516 


OPERATION    OF   THE    HOSPITAL 


from  patients,  just  an  ordinary  cash  book,  using  both  sides  of  the  page.  Each  day's 
receipts  are  kept  separate  and  turned  over  to  the  treasurer  daily  and  banked.  The 
amounts  are  entered  in  the  general  cash  book  where  all  other  cash  receipts  are 
entered,  such  as  interest  on  investments,  donations,  new  endowments,  loans  repaid, 
drug  sales,  refuse  sales,  etc.  Totals  are  posted  from  a  summary  at  the  close  of  the 
month  into  the  general  ledger.  A  cut  of  the  receipt  or  debit  side  of  the  cash  book 
is  herewith  shown  in  Fig.  181. 


Fig.  181. — Receipt  or  debit  side  of  cash  book. 


We  will  now  take  up  the  journal  entries  in  connection  with  the  receipts  side  of 
the  cash  book.  The  total  amount  from  pay  patients  is  credited  to  accounts  receiv- 
able, general  cash  account  being  debited.  If  there  are  any  refunds  to  patients 
they  are  paid  in  cash,  and  entered  in  the  petty  cash  book  for  advance  payments  not 
earned,  the  individual  account  is  charged  with  the  same,  and  accounts  receivable 
is  debited  at  the  close  of  the  month,  general  cash  being  credited.  In  case  the 
patient  has  left  the  hospital  without  having  been  reimbursed  for  advance  pay- 
ments not  earned,  a  check  is  drawn  in  the  regular  way  and  mailed. 


HOSPITAL   ACCOUNTING 


.",17 


Our  accounts  receivable  account  in  the  general  ledger  will  by  tins  time  appear 
as  follows: 

Previous  month  balance  (agreeing  will)  balance  in  patient's  ledger) 

Refunds,  advance  payments 

Accrued  earnings  from  income  register 

Cash  receipts  from  patients 

Balance  agreeing  with  balance  in  patients'  ledger 

The  general  casli  account  in  the  ledger  is  the  controlling  account  of  all  cash 
handled,  whether  it  belongs  to  the  operating  account,  endowment  account,  build- 


• 

,.,-.    ,-., 

,,...,  , 

«.v.  .. 

ie-«.  ,. 

m*.* 

"■*■ 

ssr 

__, 

.». 

JSS 

"JEr 

as; 

r._. 

as 

„_,. 

B* 

.-; 

r._ 

1 

„ 

, 

., 

10 

„ 

,, 

„ 

B 

., 

... 

, 

Fig.  1S2. — Accrued  interest  record — investment  fund. 

ing  account,  special  account,  or  any  other  cash  or  fund  account  which  may  have 
been  created.    It  may  be  suggested  that  a  separate  accounl  be  opened  at  the  bank 

for  each  fund  account.     The  proper  journal  entry  for  the  total  cash  receipt-  is  as 
follows: 

Cash  Dr. 

To  Sundry  Accounl s,  Cr. 

All  the  sundry  accounts  in  the  above  entry  having  been  posted  direct  from  the 
summary  in  the  general  cash  book,  the  credit  side  is  checked,  bul  the  debil  item  <>r 
cash  is  posted  to  general  cash  account  in  the  ledger. 


518  OPERATION    OF   THE    HOSPITAL 

Hospital  General  Account. — At  this  point  it  will  become  necessary  to  introduce 
a  new  account — namely,  hospital  general  or  operating  account.  Patients'  bills  are 
being  paid  up;  the  treasurer  is  looking  after  the  interest  payments  due  on  invest- 
ments; donations  are  coming  in,  etc.  This  money  is  all  credited  to  the  hospital 
general  account.  We  were  previously  introduced  to  two  accounts — viz.,  uncol- 
lected earnings  and  income  and  expenditure  accounts.  In  our  first  introduction 
income  and  expenditure  account  was  debited  with  the  earnings  from  patients. 

We  must  also  debit  income  and  expenditure  account  with  all  other  receipts 
applicable  to  defraying  expense.  The  uncollected  earnings  account,  as  we  have  said 
before,  is  a  summary  of  income  from  patients  and  income  from  investments.  The 
journal  entry  in  connection  with  the  receipts  side  of  the  hospital  general  account  is 
as  follows: 

Income  and  Expenditures,  Dr. .  .  . 

Uncollected  Earnings,  Dr. .  .  . 

To  Hospital  General,  Cr. .  .  . 

The  best  way  to  build  up  this  entry  from  the  cash  book  is  to  deduct  from  the 
total  cash  receipts  all  fund  account  items,  then  take  the  total  of  cash  receipts 
from  patients,  added  to  the  total  received  from  investments,  deduct  this  from  the 
remainder,  and  the  balance  will  give  you  the  sum  for  the  income  and  expenditure 
account;  the  amount  from  patients  and  investments  are  the  figures  for  uncollected 
earnings  account.  Unless  these  separations  are  made  correctly,  trouble  will  fol- 
low when  monthly  detailed  statements  are  made  up. 

Interest  on  Investments. — Investments  are  usually  made  for  a  period  of  years, 
and  interest  falls  due  quarterly  or  semi-annually,  as  the  case  may  be.  Let  us 
suppose  that  investments  are  confined  to  real  estate  loans,  interest  payable  semi- 
annually, and  your  board  of  directors  require  full  and  complete  financial  state- 
ments of  the  affairs  of  your  institution  monthly,  showing  accrued  interest  at  that 
date.  Figure  182  shows  a  form  for  a  register  to  apportion  and  record  the  accrued 
interest  which  will  be  found  practical  and  convenient. 

The  total  of  the  column  "current  charge"  is  carried  to  the  journal  as  follows: 

Accrued  Interest,  Dr. 
To  Interest,  Cr. 

The  above  being  income,  we  will  again  debit  income  and  expenditure  account, 
and  credit  uncollected  earnings  just  the  same  as  we  previously  handled  the  income 
from  patients,  and  the  following  will  be  our  journal  entry: 

Income  and  Expenditures,  Dr. 

To  Uncollected  Earnings,  Cr. 

This  concludes  our  monthly  income  receipts.  Let  us  now  review  the  journal 
entries  on  the  receipts  side  which  have  been  under  discussion : 

Accounts  Receivable,  Dr. 

To  Sundry  Items  from  Patients,  Cr. 
(See  entry  first  made  for  details.) 

Income  and  Expenditures,  Dr. 

To  Uncollected  Earnings,  Cr. 


HOSPITAL     \('<  <M\TI\<; 


:,l'.  i 


Cash,  Dr. 

To  Sundry  Arc-mints,  Cr. 

Uncollected  Ivirniiiii-,  I  )r. 
Income  and  Expenditures,  Dr. 
To  Hospital  General,  Cr. 

Accrued  Interest,  Dr. 
To  Interest,  Cr. 

Income  and  Expenditures,  Dr. 

To  Uncollected  Earnings,  Cr. 

EXPENDITURES 


Modern  business  houses  now  almost  universally  have  adopted  some  form 
of  so-called  voucher  check,  and  when  same  is  properly  endorsed  time  and  expense 
is  saved  for  both  parties,  for  no  return  receipt  is  necessary  other  than  the  endorse- 

No HOSpital   Chicago 19  


Pay  to  the  order  of_ 


DATF 

PARTICULARS 

AMOUNT 

DISTRIBUTION                          'i        AMOUNT 

1 

Banking  Co. 
Chicago.     

Fig.  1S3. — Voucher  cheek. 


Hospital. 


ment.  The  original  bills  to  which  each  vouchor  refers  on  the  face,  and  the  printed 
receipt  and  acknowledgment  on  the  back,  covers  the  ground  as  a  sufficient  ami 
valid  receipt 

On  the  back  of  this  voucher  is  printed  the  following  endorsement,  which  becomes 
effective  when  the  check  is  endorsed  for  banking  by  the  recipient: 


"Endorsement   of   th 
account   for  which   tin 
thereof." 


check   acknowledges  tl irrectness  of  the 

-aim'   is   given   and    the   receipt    in    full    payment 


After  all  the  checks  drawn  for  payment  of  outstanding  indebtedness  arc  tabu- 
lated  ami  recorded  in  the  cash  hook  the  data  will  all  be  before  us;  the  number  and 
amount  only  need  be  recorded,  unless  the  amount  belongs  to  some  special  fund  or 
unappropriated  expenditures  account,  when  a  memorandum  <<<  the  fact-  max-  be 
placed  opposite  the  entry  to  indicate  at  a  glance  the  exceptional  case.  Expense 
bills  have  been  paid  for  maintenance,  insurance  premiums,  refunds  to  patients  for 


520  OPERATION    OF   THE    HOSPITAL 

unearned  service,  and  items  in  the  fund  accounts  have  also  been  disbursed.    The 
summary  will  be  as  follows : 

Summary  of  Expenditures: 

General  accounts  (j/) 

Receivable  accounts  (refunds)  (yO 

Insurance  (j/) 

Endowment  fund 

Special  fund 

Building  fund 

Accrued  interest  (\/) 

Total 

The  items  in  the  above  summary  which  are  checked  (V),  having  been  posted 

HOSPITAL 


Fig.  184. — Credit  side  of  cash  book. 


direct  from  the  disbursement  analysis  book  in  detail,  it  only  remains  to  post  the 
fund  items.     Fig.  184  shows  credit  side  of  cash  book. 


HOSPITAL   ACCOUNTING  521 

The  journal  entries  in  connection  with  the  disbursements  will  now  be  considered, 

and  are  as  follows: 

First,  a  journal  entry  taking  care  of  the  cash  accounts  is  made  as  follows: 

Sundry  Accounts,  Dr. 

To  Cash,  Cr. 

Post  the  cash  to  the  credit  side  of  the  general  cash  account  in  the  ledger  and 
check  (V)  the  debit  side  of  the  entry  for  the  accounts  herein  represented,  which 
are  posted  direct  from  the  book  disbursement  analysis. 

The  following  journal  entry  is  then  made,  in  order  that  our  controlling  accounts 
will  be  taken  care  of  and  completed: 

Hospital  General,  Dr. 
To  Sundries, 

Income  and  Expenditures,  Cr. 
Uncollected  Earnings,  Cr. 
Unappropriated  Expenditures,  Cr. 

The  refunds  to  patients  are  taken  care  of  in  uncollected  earnings  account,  and 
the  insurance  premiums  paid  in  the  unappropriated  expenditures  account.  If 
there  are  any  disbursements  in  any  of  the  fund  accounts  post  totals  direct  to  the 
ledger. 

Insurance  Account. — Policies  of  insurance  are  usually  taken  out  for  a  period 
of  years  and  paid  for  in  full  at  the  time  the  same  are  written.  The  amount  of 
money  tied  up  in  insurance  premiums  at  times  amounts  to  thousands  of  dollars. 
It  would  not  be  good  business  to  at  once  charge  the  expense  account  with  such  a 
large  disbursement,  which  is  to  run  for  a  period  of  years,  when  under  our  system 
we  show  the  financial  standing  of  our  institution  monthly.  Therefore,  earned 
insurance  premiums  are  charged  off  from  month  to  month,  pro  rata.  The  same 
register  used  for  accrued  interest  can  be  utilized,  written  up  in  the  same  manner. 
The  total  of  the  column  "current  charge"  is  carried  to  the  journal,  as  follows: 

Unappropriated  Expenditures,  Dr. 

To  Income  and  Expenditures,  Cr. 

Insurance  is  then  charged  with  the  same  amount,  and  unexpired  insurance  is 
credited: 

Insurance,  Dr. 

To  Unexpired  Insurance,  Cr. 

In  case  investments  are  turned  into  cash,  or  have  matured  and  have  been  repaid, 
the  proper  entry  is: 

Capital  Account,  Dr. 

To  Endowment  Fund,  Cr. 

If  investments  are  bought,  the  entry  is  reversed.  The  cash  in  the  first  instance 
is  posted  direct  from  the  cash  book  to  uninvested  endowment  account,  and  vice 

versa  in  the  lat  fcer. 

With  the  exception  of  our  inaintenauee    urounts,  which  we  will  take  up  later. 


522 


OPERATION    OF    THE    HOSPITAL 


we  have  now  covered  practically  the  whole  field,  and  a  summary  of  the  journal 
entries  dealing  with  the  disbursements  is  as  follows: 

Sundry  Accounts,  Dr. 

To  Cash,  Cr. 

Hospital  General,  Dr. 
To  Sundries, 

Income  and  Expenditures,  Cr. 
Uncollected  Earnings  (Refunds),  Cr. 
Unappropriated  Expenditures  (Insurance),  Cr. 

Capital,  Dr. 

To  Endowment  Fund,  Cr. 

ANALYSIS  OF  EXPENDITURES  ACCOUNT  BOOK 

Analysis  of  Expenditures  Account  Book. — The  classification  headings  need  not 
be  printed,  but  can  be  filled  in  with  pen  and  ink  as  the  case  requires. 


r-™..,. 

Hospital 

Analysis  ol  Disbursements 

.„„..„. 

D. 

flr.,  rtJ  ,.™.,f 

1 

«■—«"-"■ 

■ 

Fig.  1S5. — Analysis  of  expenditures  account  book. 

All  invoices  for  supplies  purchased  should  be  checked  over  and  certified  by  the 
receiving  clerk  and  carefully  audited.     Monthly  statements  from  dealers  should  be 


IK  iSl'ITAL    ACCOUNTING 


523 


required  promptly  on  the  first  of  the  month,  also  checked  up  with  the  expense  Mils 
ami  passed  on  for  payment. 

The  paid  bills  are  entered  direct  to  the  expenditures  analysis  hook;  totals  for 
the  month  are  posted  direct  to  the  general  ledger.  The  aggregate  of  all  the  main- 
tenance accounts  for  the  month  will  obviously  agree  with  tin-  cash  disbursements 
or  accounts  general  in  the  cash  hook.  A  loose-leaf  hook  for  this  purpose  will  he 
found  to  best  facilitate  the  work;  the  sheets  can  he  arranged  and  rearranged  to 
suit  as  they  are  being  filled  up.  Some  departments  require  much  more  space 
than  others. 

The  expenditures  account  is  classified  as  follows: 


Maintenance. 

Provisions: 


Moat. 

Fish  and  poultry. 

Butter  and  cheese. 

Eggs. 

Milk. 

Bread  and  flour. 

Groceries. 

Vegetables. 

Fruit. 

Establishment  Charges: 

Insurance. 

Repairs  on  building. 

Taxes  and  assessments. 


Power  Plant : 

Fuel. 

Oil  and  waste. 

Miscellaneous  machinery. 

Laundry  plant. 

Expenses. 

Ice  plant. 

Salaries  and  wages: 

Power  plant. 

Office. 

Medical. 

Dispensary  and  .r-ray. 

Nurses'  training-school. 

Nurses. 

Orderlies. 

Laundry  employees 

Kitchen  employees. 

Janitors. 
Maids. 


Surgery  and  dispensary — Continued 

i-Ray. 

Hydrotherapeutic. 

Laboratory. 


Domestic: 


Crockery. 

Silverware  and  glassware. 
Cleaning  supplies. 
Kitchen  utensils. 
Hardware  and  brushes. 
Fuel  and  light. 

("Lighting. 

Repairs.     This  account.!  g™jj ?£ 
can  be  subdivided:         Heating, 

I  Laundry  plant. 

Operating-room  expenses. 

Uniforms. 

Bedding  and  linen. 

Sundries. 

Furniture  and   fixtures   (repairs 
and  renewals). 


Miscellaneous: 


Printing  and  stationery 

Postage. 

Advertising. 

Telephone  and  telegraph 

Livery. 

Freight  and  express. 
Sundry. 


Management : 


( official  salaries. 
Sundries 


Surgery  and  dispensary 

Drugs  and  drug  sundries. 

Appliances. 

Instruments. 

Wines  and  spirits. 


Direct  charges  against  income: 
1 3'  sundry  charges. 

Refunds  to  patients. 

Accrued  interest  on  investments. 
Repairs  on  real  estate  owned. 


Hospital  directors,  at  their  meetings,  should  be  furnished  with  detailed  financial 
statements  of  the  income  and  expenditures  of  the  institution,  together  with  a 


524  OPERATION    OF   THE    HOSPITAL 

balance  sheet  of  assets  and  liabilities.     A  very  comprehensive  income  and  expendi- 
ture statement  is  herewith  shown: 

Hospital. 

Statement  of  Income  and  Expenditures. 

Date 

Income.  Expenditures. 

Pay  patients:  Maintenance: 

Room  charges Provisions 

Ward  charges Salaries  and  wages 

Guest  charges Domestics 

Operating-room  charges Surgery  and  dispensary 

Surgery  and  dispensary  charges .  . Power  plant 

z-Ray  charges Rent 

Hydrotherapeutic   charges Miscellaneous 

Laboratory  charges Establishment  charges 

Milk  charges Administrative: 

Sundry  charges.  Management 

Drug  sales Excess  income  over  expenditure 

Refuse  sales 

Nurses'  registrations 

Interest  on  endowments 

Interest  on  bank  balances 

Donations 

Rents 


Hospital. 

BALANCE  SHEET 
Date 

Assets.  Liabilitiss. 

Property  and  equipment:  General  fund: 

Capitalized   expenditure   on   build-  Property  and  equipment . . 

ing  and  equipment Uninvested  capital  assets . . 

Real  estate Total  capital . 


Investments : 

Hospital  endowment  fund 

Special  investment  fund 

Cash  with  bankers: 

Uninvested  endowment  account . 

Special  account 

Building  account 

Hospital  general  fund : 

Cash  at  bank 

Petty  cash 

Accounts  receivable 

Insurance  paid  in  advance 

Accrued  interest 


Hospital  general  fund 

Add  excess  income  over  expenditures 


One  of  the  most  important  statements  in  hospital  finances,  at  least  one  which 
is  perhaps  scrutinized  the  most,  is  the  comparative  monthly  statement.  By 
enumerating  the  items  to  the  left  of  the  page  and  the  months  of  the  year  across 
the  top  of  the  page,  and  supplying  the  amounts  for  the  various  months,  a  very  com- 


HOSI'ITAL    ACCOUNTING 


prehensive  and  illuminating  group  0f  figures  will  be  .shown.    A  reproduction  of  one 

(if  tlic  headings  of  the  comparative  monthly  statement  is  as  follows: 


Maintenance: 

Salary  and  wages: 

Power  plant. 

Office. 

Medical. 

Dispensary  and  x-ray. 

Nurses'  training-school. 

Nurses. 

Orderlies. 

Laundry. 

Kitchen. 

Janitors. 

Maids. 


Jan.     Feb.     March.     April.     May.     June     July,     etc. 


Semi-annual  and  annual  comparative  statements  can  be  prepared  in  the  same 
manner,  and  some  very  interesting  percentages  can  be  shown. 


-How 

fa? 

P 

:tty  Cash  Arcount  from 

.  to 

10 

D» 

ri-ncuu- 

—  |s«|^  - 

sr  ■ 

^^ 

. 

itsaommwBina 

— . 

*-*.r™< 

""  1 

^h 

1 

| 

J 

1 

■ 

:  .. 

! 

•    - 

ill 

<-«..—* 

m 

i 

U 

Fig.  186.— Petty  cash  book. 


Another  useful   statement    in   hospital   management    is   the   schedule   shown 
below  of   per    capita    cosl    of    raw    food.     It    is    an    excellenl    check    on    the 


526 


OPERATION"    OF    THE    HOSPITAL 


commissary  department,   and  shows  as  well  the  number  of  rations  issued  for 
the  month: 

Xo.  of  days  board  issued  during  May,  1900: 

Patients 

Nurses  and  interns 

Staff  and  help 

Total 

Cost  of  provisions 

Daily  cost  of  provisions  per  capita 

Distribution  of  cost  of  provisions : 

Patients 

Nurses  and  interns 

Staff  and  help 

Total 

The  figures  for  the  above  statement  are  taken  (first)  for  the  patients'  item  from 
the  monthly  house  count  report,  which  will  be  taken  up  later;  and,  for  the  other 

HOSPITAL 


ST 

_=«,.=»„„  „ 

— 

TO. 

„™» 

- 

- 

S 

_ 

-- 

" 

W*l^.    ,U— ..»  wk  ^A-l 

W'~. 

.    - 

-                              — 

1 

1 

1     1 

i     . 

Fig.  1ST. — Superintendent's  diary. 


items,  from  the  pay-roll,  and  by  actual  count  of  those  on  the  pay-roll.  The  total 
number  of  nurses  and  interns,  together  with  the  staff  and  help,  multiplied  by  the 
number  of  days  in  the  month,  will  complete  the  figures,  or,  in  other  words,  will  give 
the  total  number  of  days'  rations  served.  The  distribution  of  the  per  capita  cost 
of  provisions  is  simply  a  matter  of  arithmetic. 


HOSPITAL   ACCOUNTING 


527 


Petty  Cash  Book. — It  will  be  found  that  a  large  number  of  small  petty  cash 
items,  such  as  car  fare,  freight,  and  express  charges,  patients'  charges,  private 
laundry,  etc.,  must  be  paid  at  once.  A  very  good  scheme  to  handle  this 
accounts  is  to  have  a  petty  cash  book,  with  a  permanent  fund  sufficiently  1  - 
take  care  of  the  business  comfortably;  for  example,  we  create  a  petty  cash  fund  of 
S250.  Whenever  this  amount  is  used  up  a  new  check  for  a  like  amount  can  In- 
issued,  and  at  the  end  of  the  month  a  check  for  an  amount  to  renew  the  S250 
can  be  issued  and  carried  forward  to  the  new  month.  The  total  for  the  month  of 
the  various  items  is  to  be  distributed  to  the  proper  expense  accounts  in  the  dis- 
bursement analysis  book  and  figured  into  the  totals  and  carried  to  the  ledger  from 
there. 

At  the  end  of  the  year  it  becomes  necessary  to  close  the  books,  and  a  very  simple 
matter  it  becomes,  for  practically  all  there  is  to  be  done  is  to  close  all  the  expense 
items  to  the  debit  side  of  the  income  and  expenditure  account,  and  all  the  income 
items  to  the  credit  side  of  the  same  account. 


SUPERINTENDENT'S    DIARY 


— 

r 

— - 

- — — 

— 

,„ 

™-, 

: . .:" 

. 

- 

• 

-■:. 

- 

i    ; 

• 

Regarding  asset  and  liability  account-  then-  is  not  much  to  be  said,  except  what 
would  apply  to  any  ordinary  business  of  equal  size.  By  referring  to  the  balance 
sheet,  previously  enumerated,  the  necessary  data  can  be  ascertained.  If  an  ex- 
penditure is  to  be  capitalized  the  usual  journal  entry  is  all  there  is  to  be  considered, 
taking  care  not  to  put  the  amount  into  the  expense  account  as  well. 


528 


OPERATION    OF   THE    HOSPITAL 


The  trial  balance  of  a  running  institution  at  the  beginning  of  the  year,  all 
things  being  equal,  would  start  out  with  the  following  accounts: 


Debit. 
Hospital  Endowment  Account. 
Building  General  Account. 
Real  Estate  Owned. 
Accounts  Receivable. 
Accrued  Interest. 
Petty  Cash  Account. 
General  Cash  Account. 
Unexpired  Insurance. 


Credit. 
Hospital  Account. 
Building  Account. 
Hospital  Endowment  Fund. 
Hospital  General  Account. 
Special  Funds  (if  any). 
Income  and  Expenditure. 
Unappropriated  Expenditures. 
Petty  Cash  Account. 


HOSPITAL  HOUSE  COUNT 

Admission  cards  for  the  day  are  not  filed  away  at  once,  but  are  kept  together 
in  a  compartment  separate  from  those  previously  attended  to  and  already  filed 
alphabetically.  The  cards  of  patients  who  have  been  discharged,  and  all  transfers 
from  one  locality  to  another  during  the  day  up  to  12  p.  M.,  are  also  kept  in  this 
compartment.  The  night  clerk  writes  up  the  superintendent's  diary  and  compiles 
the  house  count  of  patients  admitted,  discharged,  transferred,  births  and  deaths, 
if  any.  In  the  superintendent's  diary  a  permanent  general  record  of  each  patient 
is  kept,  and,  together  with  the  index  to  same,  furnishes  a  condensed  and  ready  means 
for  reference,  and  contains  nearly  everything  in  the  shape  of  records,  outside  of  the 
clinical  record  and  history,  pertaining  to  the  patient,  from  admittance  until  dis- 
charged, whether  the  patient  pays  for  the  accommodation  or  not. 

Following  the  completion  of  the  last  census,  the  government  experts  found 
fault  with  most  of  the  vital  statistics  kept  in  the  institutions  of  this  country,  on 
the  ground  that  they  were  wanting  in  certain  essentials;  notably,  there  were  not 
sufficient  family  histories  to  aid  in  calculating  the  sources  of  certain  diseases, 
such  as  cancer,  goiter,  and  tuberculosis.  The  government  sent  out  a  great  num- 
ber of  special  investigators,  whose  duty  it  was  to  set  in  motion  the  machinery 
for  better  accounting  in  the  future.  Undoubtedly,  institutions  should  attempt  to 
obtain  histories  to  the  third  generation  wherever  possible.  In  some  of  the  large 
cities  the  health  authorities  compel  [the  hospitals  to  include  in  their  death  data 
the  birthplace,  length  of  residence  in  the  country,  and  character  of  occupation  of 
at  least  two  generations  back  of  the  deceased. 

The  diary  furnishes  data  for  the  house  count,  which  is  compiled  daily  at  mid- 
night, and  is  entered  upon  six  forms. 


Form  1,  House  Count. 

November  3,  1911. 

Admissions. 

Births. 

Discharges. 

Deaths. 

Transfers. 

Free        . 
4 

1 

5 

Free    " 

$8             „ 

88         2 

$15 

810       [ 

825 

825       I 

835            [ 

Total      9 

6 

19 

HOSPITAL    ACCOUNTING 


529 


Upon  this  form  the  admissions,  discharges,  and  transfers  for  the  day  are  shown, 
together  with  the  births  and  deaths. 


Form  2,  House  Codnt. 

Novt  mix  r,  191 1. 

Kind  of 
accommo- 
dation. 

Hut.' 
l. 

Admis- 
sion. 

Dis- 
charge. 

[iiiti 

Admis- 
sion. 

Dis- 
charge. 

Date 

8. 

Admis- 
sion. 

Dl 
chargi 

Date 
4 

Etc. 

$90 

885 

I 

1 

1 

1 

$75 

1 

1 

1 

1 

$60 

1 

1 

1 

1 

850 

2 

2 
3 

2 
3 

1 
3 

$45 

2    | 

l    I        1 

2 

2 

1 

$40 

t    |        2 

S 

3 

- 

2 

2 

$35 

0               1 

2     ! 

2 

7 

2 

I 

s 

2 

2 

$25 

IB 
13 

1 

1 

14 

11 

1 

3 

IS 
12 

1 

=  1 

2 

28 
18 

Private 

Total  rooms. 

ss 

23 

3 

l 

«6 
26 

/ 
l 

S 

3 

24 

2 
#1 

A 

25 

$18 

2 

4 

#J 

1 
\ 

i 
3 

2 
3 

1 

2 
2 

$15 

* 
4 

a 

I 
4 

1 

2 
5 

1 

1=1 

2 
4 

$12 

6 
4 

#2 

l 

6 

5 

6 
5 

1 

2 

6 

4 

$10 

2* 

17 

It 
17 

2 
1 

11 

6     |           , 

S 

:; 
17 

Private 

Total  wards. 

u 

29 

#2 

1%1 

2 

29 

1 

1 
1 

19 

3 

481 

17 

J7 

$8 

4 

6 

2 

4 
8 

2 

4 
6 

4 
6 

Free. 

IB 
178 

11 

/ 
7«2 

24 

180 

s 

9 

S 
8 

181 

3 

S 

3 
9 

26 

Total  male. 

236 

16 

9 

243 

11 

11 

240 

11 

13 

238 

Tniiil  female. 

,;:, 

t 

3 

«4 

4 

B 

63 

'. 

S 

69 

Grand  total. 

301 

18 

12 

307 

15 

19 

303 

16 

21 

297 

Note.— Roman  figures,  male;  italic  figures,  female. 


Vertical  division:  Rate  admission;  discharge;  date,  continued  across  to  the  last 
day  of  the  month. 

Horizontal  division:  Hates  of  private  rooms,  total  patients  in  private  rooms 
rates  of  private  wards;  total  patient-  in  private  wards;  free  patients;  total  patients; 
grand  total. 


530 


OPERATION    OF   THE    HOSPITAL 


To  illustrate:  The  first  "date"  represents  the  first  day  of  the  month.  This 
column  shows  the  number  of  patients  in  the  hospital  at  midnight  of  the  past 
month's  last  day.  On  Form  1  the  admissions,  discharges,  and  transfers  of  the  first 
twenty-four  hours  of  the  new  month  are  found,  which  are  placed  against  the  figures 
in  the  first  "date"  column,  under  the  headings  admissions  and  discharges.  The 
number  of  patients  in  the  house  at  midnight  of  the  first  day  of  the  new  month  are 
placed  in  the  second  date  column.  These  figures  are  checked  against  the  room 
clerk's  register,  straightening  out  discrepancies  on  the  room  board  if  any.  Trans- 
fers are  marked  by  prefixing  an  X. 


Form  3,   House  Count. 


November,  1911. 


Date. 

$90 

885 
1 
1 
1 
1 

875 
1 
1 
1 

1 

860 

1 
1 
1 

850 
4 
4 
4 
4 

845 
2  ' 
3 
3 
3 

$40 
4 

5 
4 

$35 

825 

Total 
P.R. 

$18 

815 

$12 

810 

Total 
P.  W. 

!    $8 

Free. 

Grand 
total. 

1 

8          28     ' 

48 

5 

6 

10 

29 

50 

1     10 

193 

301 

2 

9 

28 

52 
49 

4 

5 

11 

29 

49 

!     12 

194 

307 

3 

10 

24 

4     j     6 
3     i     5 

11 
10 

27 

48 

10 

196 

303 

4 

8 

25 

47 

26 

44 

!    10 

196 

297 

The  headings  across  the  top  of  the  page  are  the  prices  of  the  various  classes  of 
accommodation  in  the  hospital — prices  of  rooms  and  wards. 

The  first  column  down  the  page  is  made  up  of  the  days  of  the  month,  and  day 
by  day  the  figures  carried  across  the  page  will  be  made  up  of  the  number  of  patients 
occupying  the  various  priced  rooms  and  wards  and  the  number  of  free  patients; 
the  total  of  the  day's  tabulations  across  the  page,  showing  the  number  of  patients 
of  all  classes  in  the  house,  will  be  the  last  column  for  the  day. 


Form  4 

House  Count 

November,  1911. 

Admissions. 

Discharges. 

Male. 

Female. 

Hale. 

Female. 

Date. 

P.R. 

P.W. 

$8 

Free. 

P.E. 

P.W. 

$8 

Free. 

P.E. 

P.W. 

88 

Free. 

P.E. 

P.  W. 

$8 

Free. 

1 

s#i 

10 

1 

#2 

1 

2 

2 

1 

*! 

18 

SJ 

1 

2 

3 

#2 

2 

11 

2 

2 

7  #2 

1 

1 

1 

3 

1 

1 

9 

1 

S 

3 

1 

2 

8 

2 

1 

2 

4 

«i 

3 

8 

1 

S 

4*1 

9 

4 

2 

2 

The  vertical  divisions  show  the  number  of  patients  in  private  rooms,  private 
wards,  and  free  wards,  and  the  horizontal  divisions  show  the  days  of  the  month 
and  the  number  of  patients  admitted  during  the  day  to  the  several  classes  of  accom- 


HOSPITAL    ACCOUNTING 


.531 


modationsin  the  house.     Discharges  arc  entered  on  the  righl  half  of  the  same  page 
in  the  same  way.     This  form  deals  with  changes  of  the  day. 


Form  5, 

House  Count. 

.  1911. 

Male. 

Female. 

Date. 

P.  R.             P.  W. 

S8 

Free. 

P.  R. 

P.  W. 

S8 

1  r.  . 

Total. 

l 

23                    29 

0 

178 

25 

21 

I 

15 

301 

2 

20 

29 

8 

ISO 

26 

20 

I 

11 

307 

3 

24 

29 

f. 

181 

19 

4 

15 

303 

4 

23 

27 

6 

180 

22 

17 

4 

16 

297 

This  form  deals  with  patients  in  the  house  according  to  their  accommodation. 
The  first  column  clown  the  page  is  the  days  of  the  month ;  the  headings  across  the 
page  are  made  up  of  private  rooms,  private  wards,  and  free  wards,  and  the  totals 
carried  to  the  extreme  right  of  the  page  are  made  up  of  all  classes  of  patients  in  the 
house  at  the  close  of  that  day,  and  these  totals  must  agree  with  the  same  totals 
on  Form  3. 


Form  6,  House  Count. 

November,  1911. 

Medical.     1     Surgical. 

Obstetric. 

Gynecologic. 

Total. 

Births. 

Deaths. 

Date. 

Adm. 

Disc.    Adm. 

Disc. 

Adm. 

Disc. 

Adm. 

Disc. 

Adm. 

Disc. 

i 

3 

5 

6 

6 

8 

6 

5 

17 

22 

1 
5 

Johnson.    Baby.     Hemophilia, 

1  ree  male.     11  1. 

2 

7 

3 

8 

5 

1 

2 

4 

18 

12 

Jones.   Baby.   Premature  birth. 

11  .'. 

3 

4 

3 

2 

5 

8 

10 

1 

1 

15 

19 

1 
3 

Chas.   Brown.    1869    Newberry 
Ave.     Coroner's   case.     Free 
male.     11/4. 

4 

2 

9 

5 

7 

. 

1 

3 

1 

16 

21 

1       ! 
3 

This  form  shows  the  classes  of  diseases,  and  may  bo  elaborated  or  constricted 
to  conform  to  the  demands  of  health  authorities,  or  for  purposes  of  the  annual 
report  of  the  vital  statistics  of  the  institution. 

The  first  column  down  the  page  is  the  days  of  the  month.  The  headings  across 
the  page  are  the  classified  diseases  intended  to  be  tabulated,  and  totals  are  given. 
In  this  form  arc  also  carried  columns  for  births  and  deaths  for  the  purpose  of  the 
superintendent's  reports,  shown  in  No.  12,  and  also  for  the  purposes  of  reports  to 
the  health  department  of  the  municipality. 


SUPERINTENDENT'S  REPORT 

This  form  may  be  used  for  a  report  to  the  directors,  For  a  daily  report  form  for 
any  purpose,  or  for  the  annual  report,  statistic  or  otherwise: 


532 


OPERATION    OF   THE    HOSPITAL 


SUPERINTENDENT'S  REPORT 
From  12  P.  M Q^BdbiL^LeLjSM. to  12  P.  M.J3 


tfiti. .  r?,, 


P.T^KHOSPTT^. 

"MS.S" 

«££. 

-» 

„™ 

o™„ 

«. 

mu. 

"ESS" 

Ki5S£? 

Male  Free 
a      J8.00 

m 

2 

/7 

JIM. 

.__?.9_*i. 

a 

..Jt.7t-~±. 

a.  *■/ 

c 

..7./3_ 

7*3 

33*3 

J  */ 

._    .?  */ 

s.7 

_y^ 

i.     Private  Rooms 

p-f 

If*, 

-*?.*/. 

jt 

*r 

l-f 

f  ?  . 

2-LfU- 

/ft>  *# 

/I 

,*9=r..5. 

t £.*....?.« 

3 

.«?.?...!% 

ID? 

_to_ 

13 

£ 

3 

£/ 

er 

^r 

It, 

£. 

c     $8.00 

3 

.     ../ 

..    ..#.._. 

•4 

.  /..&_ 

a./ 

3./  <*/ 

iS" 

cT 

n 

*.  Private  Rooms 

2S- 

S 

_..3o 

7__^ 

..  _3.A 

.....21 

Sub-Total 

.    L-*. 

..JJ...*> 

3 

....C^' 

'7-^ 

. 

-J..7. 

Si 

_HL 

Total 

2uio 

<T/ 

I'-f- 

...-3.Z/.... 

7/ 

3 

1± 

..221 

/i-oT 

Cash  Receipts  -  -  ■  & 

Number  of  Employees  Boarded  at  Hospital 

Number  of  Employees  Boarded  and  Lodged  at  Hospital .. 


Outstanding  Accounts  "A"       $  - 
Outstanding  Accounts  "B"       $  - 


Fig.  188. — Superintendent's  report. 


Hospital 


Summary  of  Cash  Receipts  and  Disbur 

sements  — 

Gen 

eral  Fund 

"°™ 

EDO 

r».h  ™  h.,.,,*  hfjinnln 

.  . 

fr 

r^ 

twimt  prr-prr™ 

> 

Endowment  Fund 

["*"'"-    l0 

"•"'".,■*--,                                           

Statistical  Informatic 


""" 

__„OS.  BOO 

-„,,,„,,.„„„. 

."XSIS™ 

:ssr.s  |  „.""„  I^vssa.  " 

1. 

1. 

1. 

,1 

u 

i»   |i> 

II 

1. 

•  P.n.T-Rno.P.^™, 

pm.„w.„»P.,™ 

mmw  ..p 

P.-  P.r,.™ 

IPT.I. 

"™" 

MOS. 

_ 

Fig.  1S9. — Financial  statement. 


HOSPITAL    ACCCHW'TING 


533 


Obviously  the  figures  for  this  report  arc  taken  from  one  or  other  of  the  six 
foregoing  house-count  forms.     On  the  hack  of  the  reports  may  be  tabulated,  for 
the  benefit  of  the  directors  or  subscribers,  any  special  figures  desired,  such 
number  of  private  rooms  occupied  or  the  number  of  free  patients  in  the  hospital. 

Proof  of  correctness  of  the  report:  The  sum  of  the  number  of  patient-  at  the 
beginning  of  the  period  covered  by  the  report  and  the  number  of  admissions, 

Hospital 

Statement  of  Income  and  Expenditure-,  ol  General  Fund 

For 19 .  And Months  Ending .  19 

With  Comparative  Figures  [or  Previous  Year 


MOl    tot) 

,. 

,. 

„ 

,. 

INCOME 
From  Operitkmi 

N™  Itafcu,!!™ 

TOTAL  IiK-rn,.  from  Opmlkw 

"--«;-- 

TOTAL  l.m»  .11  3e.ro 

EXPENDITURES 

r>TU   1  vrvM.ni.'Kl  . 

o-o-^fc— 

Fig.  190. — Financial  statement. 


together  with  births,  must  equal  the  sum  of  the  number  of  patients  remaining  in 
the  hospital  at  the  end  of  period  covered  by  report  and  the  number  of  discharges 

and  deaths. 

FINANCIAL  AND  STATISTICAL  STATEMENT 

It  is  becoming  more  evident  every  year  that  prospective  donors  of  large  amounts 
must  be  convinced  that  the  charities  for  which  their  gifts  are  required  are  being 


534  OPERATION    OF   THE    HOSPITAL 

conducted  along  sane  and  safe  financial  paths,  and  that  their  administrators  are 
making  good  use  of  the  funds  already  intrusted  to  them.  Then  there  are  sub- 
scribers on  the  regular  rolls  of  many  charities  who  demand  accurate  accounts  of 
stewardship  as  the  price  of  further  and  continued  gifts.  Some  of  these  charities 
are  beneficiaries  of  funds  from  corporations,  cities,  counties,  and  states,  as  well  as 
from  private  or  public  service  corporations,  and  their  responsible  heads  also  want 
to  know  what  is  being  done  with  the  funds  they  are  contributing.  To  satisfy  all 
these  classes,  who  have  a  right  to  exact  answers  to  the  questions  they  are  asking, 
at  least  by  inference,  and  for  the  purpose  of  attracting  further  and  larger  gifts,  a 
form  of  financial  statement  that  may  be  interpreted  at  a  glance  is  most  desirable. 
Sheet  No.  13  is  such  a  form,  one  that  has  met  the  demands  of  most  exacting  business 
men. 


PURCHASE  OF  SUPPLIES 

Who  Does  the  Buying  and  How? — The  question  of  who  shall  purchase  the  many 
different  kinds  of  supplies  for  an  institution  is  involved  in  that  other  and  more 
important  question  of  the  ability  and  responsibility  of  the  various  heads  of  the 
departments.  Large  hospitals  have  a  steward,  but  that  officer  usually  purchases 
food  supplies  of  a  perishable  sort  only,  and  the  other  supplies,  such  as  surgical  and 
medical  apparatus,  instruments  and  material,  linens,  drugs,  supplies  for  the  labor- 
atory of  pathology,  for  the  engineering  department,  and  for  the  janitor's  service — 
all  these  must  be  bought  by  some  one  else,  as  a  rule.  In  the  small  hospital  naturally 
nearly  everything  in  the  institution  will  be  bought  by  one  person,  and  if  that  per- 
son has  ability  as  ti  buyer  the  supplies  will  be  bought  right,  at  least  from  a  financial 
and  physical  view-point  of  the  institution.  In  some  institutions,  especially  large 
county  and  other  charitable  institutions,  nearly  everything,  from  a  paper  of  pins 
to  the  year's  coal,  is  purchased  by  contract  and  through  a  county  or  municipal 
purchasing  agent. 

It  may  be  very  well  questioned  whether  any  of  these  methods  of  buying  are 
just  exactly  the  best  way  to  get  the  best  results.  It  would  seem  that  the  pharma- 
cist could  buy  what  he  needs  better  than  anyone  else  if  he  is  the  right  sort  of  man, 
and  it  is  certainly  true  that  a  woman,  if  she  is  of  the  right  sort,  can  buy  linens, 
tableware,  bedclothing,  blankets,  patients'  gowns,  wrappers,  shoes,  kitchen  utensils, 
and  all  such  things  better  than  anyone  else,  especially  if  she  is  in  touch  with  the 
departments  where  these  things  are  used. 

Who  could  possibly  buy  operating  instruments  and  surgical  supplies  quite  so 
well  as  the  head  nurse  in  the  surgical  department,  who  is  in  constant  daily  contacl 
with  the  surgeons  who  do  the  operating,  and  who  knows  just  what  they  want? 
And  who  can  properly  buy  supplies  for  the  laboratory  of  pathology  so  well  as  the 
pathologist  himself?  And  yet  all  this  purchasing  must  be  done  in  a  businesslike 
way  and  under  a  definite  system,  by  which  receipts  of  goods,  invoicing,  billing,  and 
the  bookkeeping  can  be  kept  well  in  hand. 

In  some  institutions  the  administrative  officer  appoints  a  particular  day  in  the 
month  for  the  purchase  of  supplies  of  all  kinds;  he  has  his  heads  of  departments 
make  requisitions  for  what  they  want,  invites  merchants  to  bring  samples  of  their 
goods,  and  he  buys  from  the  samples.  He  can  send  for  the  head  of  any  depart- 
ment whose  judgment  he  may  like  to  have.  This  system,  however,  is  limited  to 
purchase  by  sample;  oftentimes  by  visiting  a  store  one  can  see  something  be  would 
very  much  prefer  to  what  be  has  been  accustomed,  and  no  such  opportunity  is 
allowed  if  the  samples  are  brought  to  the  institution.  Moreover,  there  is  a  very 
great  objection  to  purchasing  supplies  on  stated  days.  In  the  hospital,  like  even- 
where  else,  advantage  ought  to  be  taken  of  bargain  days  in  various  directions,  and 
if  we  are  going  to  buy,  no  matter  what  condition  the  market  is  in,  on  a  specified  day 
of  the  month,  we  must  take  our  chances  on  what  is  offered  that  day  and  at  the 
regular  prices. 

Almost  every  day  the  representatives  of  many  mercantile  houses  visil  institu- 
tions for  the  purpose  of  selling  goods,  and  it  often  happen-  that  great  bargains 
are  offered.      Some  of  us  arc  fortunate  enough  to  be   in  SO  close  touch  with  some 


536 


OPERATION    OF   THE   HOSPITAL 


of  our  tradespeople  that  they  will  call  us  over  the  phone  occasionally  and  notify 
us  of  some  special  offer;  if  we  confine  ourselves  to  a  special  day  to  purchase,  we  are 
not  in  position  to  take  advantage  of  these  sporadic  offerings.  Then,  again,  if  we 
wait  until  our  stock  is  low  we  deprive  ourselves  of  an  opportunity  to  look  around 
and  shop  in  a  leisurely  way,  and  we  all  know  very  well  that  if  a  merchant  has  any 
notion  that  we  are  in  immediate  need  of  a  thing  he  is  likely  to  be  much  more  inde- 
pendent than  if  he  feels  that  we  do  not  care  whether  we  buy  or  not,  and  that  he  is 
likely  to  lose  the  trade  by  allowing  us  to  shop  further;  in  that  way  we  are  oftentimes 
able  to  obtain  bargains,  especially  if  it  is  in  a  commodity  that  we  can  buy  in  large 
quantities  and  that  will  keep  indefinitely,  such  as  soaps,  glass  and  chinaware, 
linens,  gauzes  and  cottons,  blankets,  and  the  like. 

It  would  seem  that  a  very  much  better  system  can  be  employed,  one  that  is 
employed]  in  some  well-conducted  institutions.  Goods  in  these  institutions  are 
bought  on  requisition,  made  out  by  heads  of  departments  by  whom  they  are  to 
be  used,  and  this  requisition  is  laid  on  the  desk  of  the  administrator  of  the  insti- 
tution to  be  disposed  of  as  that  official  may  see  fit.  The  following  is  a  requisition 
form  of  this  sort: 

HOSPITAL  Please  quote  this 


Please  deliver  the  following 

or  advise  promptly  inability  so 

to  do: 

QUANTITY 

0esc*,p™» 

P..CE 

.Superintendent. 


Fig.  191. — Requisition  form  for  supplies. 


As  may  be  seen,  it  is  numbered  serially,  so  that  people  who  sell  goods  to  the 
institution  can  give  the  requisition  number  on  their  bills.  The  requisition  is  made 
in  book  form  in  blocks  of  100,  with  the  original  sheet  in  white  paper,  and  the 
carbon  in  some  other  color  and  perhaps  of  a  cheaper  paper.  The  head  of  the 
department  making  the  requisition  does  not  put  the  name  of  the  firm  from  which 
the  articles  are  to  be  purchased,  but  heads  of  departments  are  instructed  to  make 
out  a  separate  requisition  for  each  kind  of  goods  to  be  bought,  so  that,  if  desirable, 
the  superintendent  may  fill  out  the  head  of  the  requisition,  forward  it  to  some  one 
merchant,  and  order  the  bill  from  him.  In  the  Michael  Reese  Hospital  it  is  the 
custom  to  have  one  of  these  requisition  books  in  the  hands  of  the  chief  engineer, 
the  superintendent  of  nurses,  the  housekeeper,  the  pharmacist,  and  the  director 


PURCHASE   ni     m  PPLIES  531 

of  pathology.  The  requisition  Mocks  are  fastened  into  one  of  the  ordinary  spring- 
form  holders,  made  in  the  proper  size  and  shape,  with  the  name  of  the  departmenl 

to  which  it  belongs  on  the  cover.  The  department  head  make-  out  the  requisition 
whenever  goods  are  needed,  and  forwards  it  to  the  superintendent,  who  may  either 
purchase  the  supplies  himself,  over  the  telephone  or  in  person,  or  he  may  sign 

and  return  it  to  the  department  head  from  which  it  came,  with  the  name  of  the 
department  head  written  diagonally  across  the  lace  of  the  requisition  in  pencil, 
indicating  that  he  or  she  is  to  personally  purchase  the  goods  ordered,  using  the 
requisition  as  the  order  on  the  merchant  and  as  authority  to  make  the  purchase 
in  the  name  of  the  hospital. 

At  the  end  of  the  month,  or  whenever  the  bills  are  to  be  approved  by  the 
superintendent,  all  these  requisition  hooks  are  laid  upon  his  desk,  and  by  reference 
to  them  he  may  settle  the  question  of  the  purchase  price  or  quality  or  quantity  of 
any  goods  ordered,  and  compare  these  with  the  invoices  and  statements  covering 
the  accounts. 

Constant  watchfulness  must  be  practiced  in  the  purchase  of  perishables,  fruits 
and  vegetables  especially.  It  is  a  common  practice  with  many  marketmen  to  sell 
one  crate  of  goods  to  a  purchaser  on  the  spot  and  to  deliver  an  entirely  different 
commodity.  Sometimes  this  is  not  deliberate  deception.  Someone  else  may  come 
along  presently,  buy  and  take  away  with  him  precisely  the  same  samples,  and  the 
merchant  will  find  later  that  he  has  not  a  sufficient  amount  to  make  the  hospital 
delivery  as  ordered;  the  temptation  will  be  very  great  to  substitute  "something 
just  as  good." 

Of  course  vigilance  at  the  receiving  room  will  protect  the  institution  ag 
such  dishonesty,  and  the  goods  can  be  ruthlessly  returned,  and  there  will  be  a 
counter  temptation  on  the  part  of  the  steward  to  delay  the  return  of  ihe  goods 
until  they  are  spoiled  for  the  merchanl ,  but  very  often  they  are  wanted  so  badly  and 
so  soon  that  there  will  not  be  time  to  make  the  exchange,  and  the  indifferent  thing- 
will  have  to  be  used. 

There  is  a  better  way  to  guarantee  the  delivery  of  the  goods  purchased,  and 
that  is  to  establish  a  reputation  among  marketmen  for  quitting  for  good  a  mer- 
chant who  is  caught  cheating.  If  there  are  a  few  examples  of  marketmen,  scattered 
about  the  town,  who  cannot  sell  the  institution  a  penny's  worth  of  anything,  and. 
if  the  institution's  bills  are  paid  promptly  and  the  trade  worth  having,  it  will  not 
be  long  before  the  market  ethics,  at  least  so  far  as  that  institution  is  concerned. 
will  be  on  a  pretty  high  plane. 

THE  STOREKEEPER 

All  goods  purchased  for  an  institution  should  be  received  by  one  person — 
the  storekeeper  employed  as  custodian  of  the  institution's  stocks  of  every  sort. 
All  goods  purchased  should  be  accompanied  to  the  hospital  by  the  invoice-,  which 
state  specifically  quantities  and  qualities  and  designate  in  detail  what  thi 

are,  and  no  mailer  who  1  he  purchaser  was,  whether  the  superintendent  himself,  or 
the  steward,  or  the  head  of  one  of  the  department-,  all  goods  should  be  received  in 
the  storeroom  of  the  institution,  signed  for  by  the  storekeeper,  who  checks  them 
from  the  accompanying  invoices,  either  by  weight  or  count,  before  they  are  signed 
for.    The  storekeeper  should  immediately  notify  the  business  office  of  the  receipl 

of  the  goods,  and  through  this  channel  the  head  of  the  department  ordering  them 

is  notified  of  their  receipt,  and  can  then  requisition  them  out  of  the  storekeeper's 
custody,  this  requisition  being  signed  also  by  the  superintendent  of  the  institution 


538 


OPERATION    OF   THE    HOSPITAL 


or  some  one  delegated  by  him. 


<     Q 


CO 

</> 

H 

© 

X 

Es 

to 

W 

w 

u 

OS 

« 

-J 

o 

< 

H 

IX 

s 

o 

Cu 

w 

OS 

►« 

_) 

<: 

Q 

a 

N           3 

*        © 

E 

•< 

1       'C 

ft. 

8j 

a 

a 

2 

(S 

"3 

"is 

S 
o 
ja 

1 

At  the  close  of  the  day's  work  the  storekeeper 
should  send  all  invoices  received  during  the  day 
to  the  accounting  department  of  the  institution, 
accompanied  by  a  list  of  the  receipts  and  distribu- 
tions for  the  day,  made  out  in  a  form  as  indicated 
by  Fig.  192. 

Following  these  papers  just  one  step  further  in 
the  accounting  department,  these  invoices  are  filed 
from  day  to  day  under  alphabetic  heads  by  names 
of  mercantile  firms,  and  the  receipt  and  distribu- 
tion sheets  are  kept  in  folder  book  form  by  dates. 
At  the  end  of  the  month  the  invoices  are  all 
attached  to  the  monthly  statement,  and  the  state- 
ments with  their  accompanying  invoices  are  sent 
by  the  accountant  to  the  head  of  the  department 
to  which  they  belong  for  O.  K.  or  comment.  For 
instance,  the  goods  may  not  have  been  satisfac- 
tory, and  it  is  desired  that  they  be  returned,  or, 
indeed,  they  may  have  been  returned,  and  it  will 
be  the  part  of  the  head  of  the  department  to  so 
state  on  the  invoices  involved,  although  such  re- 
turn is  also  shown  on  the  storekeeper's  daily 
report  and  noted  by  the  accountant. 

At  the  time  set  for  the  approval  of  the  bills 
the  superintendent  of  the  institution  has  before 
him,  for  his  information,  the  monthly  statement 
with  the  checkings  of  the  accounting  department, 
the  invoices  upon  which  the  statement  is  based, 
each  invoice  being  approved  or  disallowed  by  the 
head  of  the  department  involved,  and  the  requisi- 
tion books  covering  the  purchases  of  all  the 
articles.  In  this  way  the  accounts  for  the  month 
can  be  carefully  checked,  and  it  will  hardly 
happen  that  a  mistake  can  be  made  by  all  the 
people  who  have  handled  each  separate  account. 

The  keystone  to  the  purchase  of  supplies  and 
their  proper  distribution  is  the  personnel  of  the 
storekeeper.  Nearly  every  one  in  the  institution 
will  undertake  to  obtain  supplies  from  the  store- 
keeper without  proper  requisition,  and  upon  his 
strength  or  weakness  will  depend  the  integrity  of 
the  stockkeeping  department. 

Stock  Inventory. — There  is  a  very  grave 
question  in  hospital  administration  whether 
stock  inventories  shall  be  kept.  Some  of  the 
greatest  mercantile  houses  in  the  world  make 
no  effort  to  keep  an  inventory  of  stock,  on  the 
ground  that  the  expense  of  keeping  the  in- 
ventory properly  will  vastly  overbear  any  pos- 
sible losses  from  a  failure  to  keep  such  an  ac- 
count.    In  some  institutions  there  is  a  careful 


PURCHASE    OF   St  PPLIES  539 

stock  account  kept,  hut  it  is  very  problematic  whether  such  an  account  is  of  any 
very  great  value.     Undoubtedly  it  is  convenient  for  the  superintendent  of  an 

institution  to  be  able  to  go  to  a  card  index  and  see  the  state  of  his  stock  in  any  item 
at  any  time,  and  some  administrators  urge  this  card-index  inventory  system,  because 
it  keeps  them  posted  as  to  the  amount  of  supplies  that  are  being  used,  and  it  keeps 
them  posted  in  regard  to  stocks  from  day  to  day,  but  the  accounting  department 
likewise  keeps  them  posted  from  month  to  month,  so  that  the  difference  is  not 
great  in  the  course  of  a  year.  One  is  not  liable  to  run  short  of  stock  in  any  particu- 
lar department,  even  without  a  card  index  of  stock,  because  the  heads  of  depart- 
ments are  keeping  their  own  accounts  separately  and  in  their  own  simple  way,  and 
they  will  announce  by  new  requisition  from  time  to  time  the  low  state  of  stock  in 
any  item. 

In  small  institutions,  where  one  person  does  the  buying  and  also  keeps  the 
stores,  it  may  be  found  convenient  to  keep  a  card  index  of  all  but  the  daily  food  sup- 
plies. There  should  be  a  space  for  additions  to  stock  whenever  received  and  other 
spaces  to  indicate  withdrawals  on  requisition. 

PURCHASE  OF  MEDICAL   AND  SURGICAL  SUPPLIES 

Gauze  and  Cotton. — Three,  possibly  four,  kinds  of  gauze  should  be  used  in  the 
institution  if  we  are  to  get  the  most  economic  service.  First,  we  must  have  a 
finely  wfoven,  rather  heavy  gauze  for  bandages  if  the  institution  makes  its  own 
bandages.  Some  institutions  use  a  very  much  lighter  bandage  than  others,  and 
some  use  a  heavier  bandage  in  the  narrower  widths  than  in  the  broad  widths,  and 
this  is  a  matter  that  the  surgeons  will  have  to  determine  finally.  The  next  mesh 
of  gauze  is  for  sponges  and  packs  in  the  operating-room.  All  these  pieces  must  lie 
hemmed  on  the  edges,  to  keep  threads  from  falling  into  the  wound  and  setting  up 
inflammatory  conditions  after  the  operation,  and  about  20  by  30  mesh  gauze  will 
answer  this  purpose  very  well.  Then  there  is  a  third  quality  of  gauze,  and  in  some 
institutions  the  third  and  fourth  quality  are  merged  into  one,  but  it  would  seem  a 
little  better  practice  to  have,  say,  a  20  by  24  mesh  gauze  for  the  first  dressings  and 
for  dressing  patients  with  open  wounds  in  which  the  threads  are  likely  to  get  into 
the  wound.  The  very  coarse  mesh  gauzes  are  loosely  made  of  short  fiber  cotton, 
and  in  cutting  there  are  nearly  always  short  threads  left.  The  fourth  quality,  Hi 
by  20  mesh,  is  the  great  bulk  of  the  gauze  used  in  the  institution  for  dressing  and 
operating-room  purposes.  This  gauze  forms  the  outer  dressings.  It  i~  the  gauze 
used  to  soak  up  fluids  in  drainage  operations,  and  in  some  institutions  it  is  used 
instead  of  oakum  in  cases  of  fecal  fistula^,  though  the  oakum,  while  not  quite  so 
absorbent,  is  very  much  cheaper,  and  can  consequently  be  changed  oftener,  and 
it  will  retain  its  antiseptic  condition  very  much  longer  than  any  gauze. 

Let  us  now  very  briefly  discuss  the  economies  of  bandage  material.  We  can 
buy  very  excellent  bandages  already  made  up  and  fastened  with  a  pin  for  about 
40  cents  a  pound  most  of  the  time,  and  we  can  buy  the  gauze  needed  to  make  that 
much  bandages,  and  of  the  right  texture  nauze  for  about  S3  per  L00  yards 
when  raw  cotton  sells  at  15  cents  a  pound;  or  if  we  do  not  buy  very  large  quantities, 
up  into  the  hundreds  of  thousands  of  yards  at  a  time,  it  will  cost  $3.25,  ami  these 
figures  are  so  nearly  the  actual  cost  of  the  cotton  in  the  bandages,  not  counting  the 
labor  and  losses  of  rolling,  that  it  is  hardly  conceivable  that  it  will  pay  us  any 
longer  to  roll  our  own  bandages. 

For  sponge  and  packing  purposes,  gauze  can  1m-  purchased  at  about  $2.25  per 
100  yards,  that  is  20  by  24  mesh,  but,  where  only  small  quantities  of  this  are 


540  OPERATION    OF   THE    HOSPITAL 

needed,  we  have  to  pay  a  larger  price.  In  some  institutions  that  roll  their  own 
bandages  the  bandage  gauze  is  also  used  for  sponges  and  packing,  and  perhaps  this 
is  just  as  well,  because  much  larger  quantities  are  bought,  and  .thereby  the  price 
is  reduced.  The  cheaper  gauze  runs  from  $2.25  down  to  $1.90  per  100  yards, 
excepting  at  those  peculiar  commercial  periods  in  which  the  cotton  market  is  being 
manipulated  either  by  the  growers  or  the  mills,  and  these  periods  are  alluded  to  for 
the  purpose  of  suggesting  to  hospital  administrators  that  it  will  pay  them  well  to 
watch  conditions  in  the  cotton  market,  and  especially  to  watch  the  New  York 
cotton  quotations  as  indicating  manipulation  of  the  commodity;  for  instance, 
as  this  chapter  is  being  written  it  just  happens  that  the  mills  in  the  East  have  short- 
ened their  operating  season,  and  have  made  an  agreement  to  curtail  production 
something  like  25  per  cent. 

The  best  way  to  buy  cotton  for  almost  any  purpose  is  to  buy  in  very  large 
quantities,  enough  to  last  a  year  or  more,  when  the  price  is  right.  There  is  very  lit- 
tle opportunity  to  manipulate  the  fiber  of  gauze  cottons,  and  we  can  usually  expect 
that  hospital  gauzes  will  be  made  up  of  a  fairly  long  fiber  cotton.  Once  in  a  while 
some  one  mill  may  turn  out  an  immense  quantity  of  a  short  fiber  material,  and  take 
the  chances  of  marketing  it  before  the  fact  of  its  inferiority  is  recognized.  A  magni- 
fying glass  will  discover  this  method  of  marketing  to  be  an  inferior  one. 

The  purchase  of  absorbent  cotton  is  based  upon  practically  the  same  principles 
as  those  involved  in  the  purchase  of  gauzes.  Hospital  cottons  of  all  sorts  are  packed 
in  small  packages  and  made  up  into  bales  of  100  packages.  It  is  fairly  presumable 
that  the  mills  themselves  send  out  an  evenly  graded  cotton  of  the  absorbent  kinds, 
especially  where  the  mill  brands  are  attached,  but  there  is  no  question  that  very 
often  these  cottons  reach  us  in  an  absurdly  different  condition  than  was  represented 
to  us  when  the  commodity  was  bought.  We  sometimes  pay  15  cents  for  a  hospital 
cotton,  whereas  we  might  have  purchased  another  cotton  called  hospital  cotton  for 
2  cents  less,  and  then  find  on  opening  a  bale  that  the  high-priced  cotton  is  of  so  short 
a  fiber  that  it  is  practically  a  waste.  Hospitals  ought  to  return  such  goods.  They 
are  fraudulent,  and  we  cannot  be  made  to  keep  them  and  pay  for  them. 

But  there  is  a  vast  difference  between  brands  of  long  fiber  absorbent  cotton, 
and  shipments  of  the  same  brand  in  different  seasons  will  prove  vastly  different, 
especially  in  the  quality  of  absorption.  We  may  readily  detect  this  difference  by 
taking  two  pieces  of  as  nearly  the  same  size  as  the  naked  eye  can  detect  and  drop 
them  into  a  basin  of  water,  without  squeezing  the  particles  together.  If  the  two 
samples  are  taken  from  the  same  bale  they  will  usually  submerge  at  exactly  the 
same  time,  but  we  may  take  two  samples  again,  out  of  two  different  bales,  that  look 
exactly  alike,  but  one  sample  will  submerge  a  definite  length  of  time  ahead  of  the 
other,  indicating  a  better  power  of  absorption.  This  difference  is  due  to  poor  clean- 
ing of  the  cotton  and  poorer  treatment.  Cottons  can  be  easily  bleached  without 
being  well  cleaned,  and  it  costs  a  good  deal  of  money  to  clean  cotton  properly,  and 
the  proportion  of  waste  is  increased  vastly  in  the  cleaning  process;  therefore,  the 
mills  can  make  money  by  palming  off  poorly  cleaned  and  poorly  bleached  absorbent 
cotton,  and  some  of  them  do  so.  We  should  all  test  our  cottons  before  purchasing, 
and,  if  we  are  purchasing  large  quantities  by  sample,  we  ought  to  make  very  care- 
ful tests  of  the  absorbtive  properties  as  well  as  fiber  lengths,  and  these  tests  ought 
to  be  made  under  the  eye  of  the  representative  of  the  mill,  and  the  weight  of  the 
samples  ought  to  be  taken  exactly,  and  the  exact  time  that  it  takes  them  to  be 
submerged  in  water  ought  to  be  taken,  and  there  ought  to  be  many  samples  tested 
in  this  way — a  dozen  or  more.  For  given  weights  the  time  of  submergence  will 
be  practically  the  same  in  all  the  samples  out  of  a  single  package.     Then,  if  a  differ- 


PURCHASE   OF   si  PPLIES  .".11 

cnt  cotton  is  shipped  to  us  on  the  order  which  we  giveal  the  end  ol  these  tests,  we 
have  a  recourse  and  can  refuse  to  receive  the  inferior  Btuff. 


LINENS  AND  COTTONS 

The  kind  of  linens  to  be  used  in  institution  service  will  depend  on  a  good  many 
conditions,  and  we  must  take  these  conditions  into  account  when  we  purchase  these 
commodities.  For  a  large  charity  hospital,  for  instance,  there  are  very  coarse  but 
very  strong  fabrics  that  will  last  a  long  time,  and  that  ran  lie  purchased  at  prices 
far  below  the  finer  woven  fabrics  and  those  woven  in  figures.  Sheet-,  spreads, 
pillow  cases,  and  table  linen  can  all  lie  had  in  this  coarser,  cheaper  grade  of  goods 
that  wall  stand  the  wear  and  tear  of  the  laundry,  because,  after  all  is  said  ami  dune, 
it  is  not  the  wear  that  institution  goods  receive  that  destroys  them,  but  the  laundry. 
Take,  for  instance,  an  institution  where  the  linens  are  in  constant  circulation, 
that  is,  where  there  is  not  sufficient  quantity  to  allow  any  of  them  to  rest  on  the 
shelves,  these  things  will  be  busy  almost  every  day.  It  isn't  the  use  of  a  sheet 
for  a  few  hours  on  a  patient's  bed  that  wears  it  out — it  is  the  hard  service  of  going 
through  the  laundry,  first  in  the  counting,  next  in  transportation  to  the  laundry, 
rough  handling  in  the  recount,  then  through  the  washer  and  then  the  wringer,  then 
the  mangle,  and,  finally,  the  folding  and  transportation  back  to  the  linen  room,  and 
the  counting  and  recounting  for  distribution  to  the  auxiliary  linen  departments 
of  the  institution  and  the  handling  of  the  nurses  in  putting  on  and  taking  off  the 
beds.  So  that,  when  we  buy  linens  for  an  institution,  we  must  consider  t  he  laundry 
service  as  almost  the  prime  factor  influencing  our  decision  in  the  fluidity  to  be  pur- 
chased. For  private  patients  and  in  small,  well-disciplined  institutions,  where 
there  is  a  careful  watching  of  the  linen,  we  can,  as  a  rule,  afford  better  qualities  of 
goods — in  fact,  we  cannot  afford  cheap  goods  at  any  price.  And  even  for  the  use 
of  the  public  wards  and  in  charity  hospitals  we  cannot  afford  to  use  the  cheap, 
flimsy,  short-fiber  cottons  and  linens.  These  wear  out  too  quickly  to  make  them 
serviceable  at  any  price. 

We  have  said  something  about  those  institutions  in  which  the  linen  supply  is 
so  short  that  the  goods  are  kept  constantly  in  motion,  and  there  i-  not  enough  to 
allow  them  to  rest  any  time  on  the  shelves.  The  advantage  and  disadvantage  of 
keeping  the  fabrics  in  motion  presents  a  real  problem  in  institution  management. 
We  are  often  asked  the  question,  "Which  is  the  best  economy  in  the  long  run.  to 
keep  things  moving  and  to  be  short  of  -lock  most  ol'  the  time,  or  to  have  plenty 
of  stock  on  hand  and  keep  the  shelves  of  the  general  linen-supply  rooms  tilled?'' 
Perhaps  the  solution  of  the  question  will  be  a  personal  one,  and  will  rather  concern 
the  rigidity  of  management  and  the  care  and  watchfulness  of  the  people  using  the 
stock  than  a  question  that  can  be  settled  bj  any  hard-and-fast  rule.  This  sug- 
gestion mighl  be  made,  however:  Everybody  using  material  of  any  kind  in  an 
institution  is  very  much  more  apt  to  be  wasteful  if  it  is  generally  understood  thai 
there  is  plenty  more  where  thai  came  from  than  where  it  is  the  common  knowledge 

that  the  stock  is  low  and  the  things  hard  to  get.  Especially  does  this  temperamental 
attitude  prevail  with  the  nurses,  and  even  more  especially  with  the  graduates  who 
may  be  on  private  cases  in  the  institution.  These  young  women  will  generally 
requisition  about  all  the  supplies  that  they  think  they  can  get,  and  a  good  many 
of  them  will  work  overtime  to  see  that  their  supplies  are  used  up.  But  if  they  know 
their  linen  requisitions  are  going  to  be  cut,  and  made  to  con  form  to  the  judgment  of 
the  head  nurse  in  charge  of  the  supplies  or  the  women  of  the  linen  room,  they  are 
ver\    much  more   apt    to   think  twice   before  they  wipe-  up  a    spol  of  Mood  with  a 


542  OPERATION    OF   THE   HOSPITAL 

clean  sheet  and  then  throw  it  in  the  spoiled  linen  receptacle.  And  if  the  linen  is 
known  to  be  scarce,  the  nurses  will  be  very  much  less  apt  to  use  clean  sheets  under 
Kelly  pads  for  soaking  up  the  dressing  waters,  and  the  same  will  be  true  of  the 
towels  and  pillow  slips  and  all  of  the  other  linen  supplies. 

Now,  let  us  go  back  for  just  a  moment  more  to  the  quality  of  linens  and  cottons. 
In  a  final  analysis  of  cost,  there  are  two  features  in  fabrics  that  make  up  the  expen- 
siveness  or  cheapness  of  the  goods ;  one  of  them  is  the  weight  of  the  material,  because 
the  raw  material  is  sold  by  the  pound,  and  the  other  factor  is  the  amount  of  mill 
work  put  into  the  goods.  A  third  factor,  perhaps,  is  the  quality  of  the  fiber  used, 
but  this  factor  may  also  be  included  in  the  pound  price  of  raw  material. 

There  is  no  economy  whatever  in  buying  short-fiber  stuff  for  any  purpose  what- 
ever, whether  it  be  curtain  material,  bed  linens,  or  even  floor-mops.  A  great  deal 
of  short-fiber  raw  material  is  essentially  a  waste  product.  It  is  woven,  in  its  final 
treatment  in  the  mills,  into  tight  and  apparently  very  good  threads,  and  these 
threads  are  made  into  apparently  very  good  cloth,  and  there  is  only  one  way  to 
detect  the  short-fiber  material,  and  that  is  a  process  of  actual  dissection,  by  taking 
a  magnifying  glass  and  a  needle  and  by  raveling  out  a  thread  here  and  there  and 
then  by  untwisting  the  thread.  This  is  a  delicate  process,  but  it  pays  handsomely 
to  make  these  dissections  of  linen,  cotton,  and  woolen  fabrics.  We  may  set  it 
down  as  a  definite  rule  that  short-fiber  stuffs  will  not  last,  and  that  they,  of  all  others, 
are  the  ones  to  go  to  pieces  in  the  laundry.  Processes  of  manufacture  are  so  perfect 
nowadays  that  there  is  no  telling  by  even  the  finest  trained  eye  whether  a  piece 
of  goods  is  made  of  short  or  long  fiber,  except  in  the  process  of  dissection  alluded  to. 

BLANKETS 

There  are  several  considerations  surrounding  the  purchase  and  use  of  blankets 
for  institution  service.  Where  we  must  equip  the  beds  of  private  pay  patients  we 
can  hardly  afford  to  quibble  over  the  price  of  blankets,  and  we  must  buy  the  kind 
that  will  not  only  give  the  greatest,  but  most  comfortable,  wear  under  the  existing 
conditions.  It  is  impossible  to  wash  or  renovate  a  part  wool  and  part  cotton  blanket 
and  have  it  retain  that  peculiarly  soft,  luxurious  feel  that  it  had  when  new.  It 
might  be  said,  however,  that  even  the  very  best  of  wool  blankets  can  be  quite  as 
readily  spoiled  in  the  laundry  as  the  cheapest  sort  of  cotton-wool.  But  no  care  can 
ever  bring  a  cotton-wool  blanket  through  the  laundry  and  leave  it  fit  for  a  luxury- 
loving  patient's  bed.  So  it  would  seem  that  about  the  only  thing  we  can  do  is  to 
buy  an  all-wool  blanket  for  private  patients.  And  if  we  are  to  concede  so  much,  let 
us  go  one  step  further  and  have  bright,  cheery  patterns  in  our  blankets  for  the 
private  patients.  If  we  have  a  children's  department,  the  same  general  rule  ought 
to  be  adhered  to.  The  blankets  ought  to  be  all  wool  and  in  cheery  patterns  of 
bright  colors. 

Good  all-wool  blankets  that  will  be  satisfying  to  rich  people,  who  are  paying 
enough  in  the  institution  to  justify  what  they  have  been  accustomed  to  at  home, 
cost  all  the  way  from  $3  to  $5  for  a  5-pound  double  blanket,  and  the  prices  are 
going  up  rather  than  coming  down.  This  isn't  all  that  these  blankets  cost,  however, 
because  they  must  be  renovated  frequently,  and  few  institution  laundries  are 
equipped  to  do  this  cleaning  of  all-wool  blankets  and  to  make  them  come  back 
again  into  the  fiuffiness  so  delicious  in  a  sick  bed;  and,  if  we  are  to  have  these 
blankets  cleaned  by  people  regularly  engaged  in  the  business,  and  who  can  do  it 
as  experts,  the  cost  will  vary  from  20  cents  for  a  single  blanket  up  to  40  or  50  cents 
for  a  pair,  and  we  have  to  be  very  careful  about  the  business  house  to  which  we 


PURCHASE   OF  si  1TL1ES  543 

entrust  our  all-wool  blankets,  because  many  of  them  are  spoiled  in  the  cleaning. 
It  will  not  do  to  clean  these  blankets  once  or  twice  a  year,  because  well-to-do  people 
are  also  fastidious  people,  and  they  do  not  care  to  use  blankets  that  have  been  used 
by  others,  and  especially  by  other  sick  people.  There  is  no  telling  when  an  infec- 
tion may  be  carried  from  one  sick  bed  to  another  by  the  common  use  of  blankets. 
We  would  hardly  think  of  giving  a  sheet  to  a  patient  that  had  been  used  by  another 
patient,  and  it  is  common  for  us  to  explain  this  by  the  suggestion  that  sheets  are 
placed  next  to  the  body  while  blankets  are  not ;  but  this  is  only  partly  true.  Often- 
times a  blanket  is  up  about  a  patient's  neck,  and  the  patient  breathes  into  the  body 
of  the  blanket,  and  oftentimes  parts  of  the  naked  body  do  touch  the  blanket;  so 
often,  in  fact,  that  it  is  unpardonable  to  ask  a  patient  to  use  a  blanket  that  has  been 
used  by  some  one  else  until  it  is  renovated  and  cleaned  or  at  least  thoroughly 
sterilized. 

In  the  wards  of  the  hospital  we  are  confronted  with  a  somewhat  different  prob- 
lem. We  want,  it  is  true,  to  use  a  comfortable  blanket  for  the  sick,  but  we  must 
also  think  of  other  considerations — for  instance,  the  length  of  wear  that  we  must  get 
out  of  it,  and  the  fact  that  we  must  wash  the  ward  blankets  in  our  own  laundry. 
Therefore,  they  must  not  shrink  too  much  when  they  are  washed,  because  in  the 
very  best  of  our  institutions  the  laundry  wTork  will  shrink  blankets. 

A  blanket  composed  of  about  40  per  cent,  of  wool  and  about  60  per  cent,  of 
cotton  is  commonly  used  on  the  ward  beds,  but  there  is  a  queer  thing  about  this 
sort  of  a  blanket.  Almost  all  of  the  40  per  cent,  of  wool  that  the  manufacturers 
guarantee  to  us  is  in  the  nap  of  the  goods — in  other  words,  if  the  nap  were  all  taken 
out,  which  is  pretty  much  the  case  after  the  first  wash  in  the  average  laundry,  we 
have  about  10  per  cent,  wool  or  less,  and  the  rest  of  the  blanket  is  a  very  loosely- 
woven  cotton  fabric.  That  kind  of  a  blanket  doesn't  look  like  very  much  after  it 
comes  out  of  the  laundry,  because  it  loses  most  of  its  nap  there.  These  40  per 
cent,  wool  and  60  per  cent,  cotton  blankets  cost  about  $2.50  for  a  5-pound  pair. 
They  last  a  great  deal  longer  than  an  all-wool  blanket  on  the  ward  beds,  but  it  isn't 
by  any  means  because  they  are  better  blankets.  It  is  rather  because  we  are  satis- 
fied with  a  tolerably  poor  blanket  on  our  ward  beds.  The  fact  of  the  business 
is  that  if  we  undertook  to  use  an  all-wool  blanket  on  the  ward  beds  and  then 
attempted  to  maintain  any  sort  of  asepsis  and  regard  for  the  rules  of  cleanliness  of 
our  patients,  we  could  not  at  all  afford  to  use  an  all-wool  blanket  because  of  the 
great  cost  of  frequent  cleaning.  If  the  average  laundry  undertook  to  clean  or  wash 
an  all-wool  blanket  it  would  shrink  about  one-fourth  of  its  dimensions  with  each 
wash,  until  it  would  soon  fit  the  children's  beds.  And,  after  all,  it  seems  that  we 
are  almost  thrown  back  upon  the  necessity  of  accepting  the  shoddy  cotton-wool 
blankets  for  our  wards,  and  then  make  the  very  best  bargain  we  can  out  of  the 
transaction  by  washing  the  blankets  in  water  that  is  not  hot  enough  to  shrink  them. 
In  other  words,  all  the  blankets,  whether  they  lie  wool  or  cotton,  will  have  to  be 
washed  in  cold  or,  at  best,  lukewarm  water  to  prevent  them  from  shrinking,  and 
then,  under  the  very  best  of  conditions,  the  mixed  blanket  is  pretty  apt  to  lose  most 
of  its  woolen  constituent. 


COATS,  GOWNS,  MANTLES,  AND  UNIFORMS 

There  are  three  forms  of  white  garments  used  in  the  institution  for  ordinary 
wear  in  addition  to  the  white  uniforms  of  the  interns,  head  nurses,  and  heads  of 
departments.  The  first,  the  surgeons'  operating  gown:  the  next,  the  visitors' 
house  coat,  which  is  also  worn  by  the  surgeons  and  physicians  ><\  the  institution 


544  OPERATION    OF   THE    HOSPITAL 

in  making  their  rounds;  and  third,  the  mantle,  a  sleeveless  garment,  made  almost 
like  a  pillow  case,  with  a  hole  in  one  end  for  the  head  and  without  sleeves,  for 
visitors  in  the  maternity  and  children's  departments  and  in  the  operating-rooms. 

These  coats  and  gowns  are  usually  made  of  a  drilling,  or  Indian  head,  but  there 
are  many  qualities  of  both  of  these  grades  of  cotton  goods.  Drilling  signifies  noth- 
ing, and  Indian  head  signifies  hardly  more,  since  either  of  them  can  be  bought  for 
almost  any  price,  and  it  may  need  to  be  suggested  only  that,  whether  the  gar- 
ments are  made  of  drilling  or  Indian  head,  the  very  best  material  should  be  used, 
which  means  the  highest  prices  must  be  paid,  because  these  garments  are  very  fre- 
quently sent  to  the  laundry,  not  because  they  are  soiled,  but  because  it  is  supposed 
that  they  may  be  unsterile,  and  unless  the  cloth  out  of  which  they  are  made  is  of 
the  very  best  they  are  soon  torn  to  pieces. 

The  operating-room  gowns  are  usually  opened  in  the  back,  and  the  best  ones 
are  tied  with  tapes,  one  at  the  neck,  one  at  the  waist  line,  and  one  in  between. 
The  gowns  reach  to  the  knees  of  the  surgeon,  and  if  they  are  made  with  half-sleeves 
they  will  last  very  much  longer,  and  the  laundry  account  will  be  reduced  mate- 
rially, because  the  surgeon  can  then  pin  on  a  new  sleeve  for  each  operation  without 
having  to  remove  the  whole  gown.  Of  course,  some  surgeons  go  through  a  whole 
morning's  work  with  one  gown,  whether  it  be  a  sleeveless  one  or  has  long  sleeves, 
but  in  some  institutions  it  is  a  part  of  the  technic  of  the  operating  department  to 
change  the  surgeon's  sleeves  with  each  operation  and  with  each  change  of  gloves. 

There  is  very  little  to  be  said  about  the  hospital  visitor's  coat,  excepting  that  it 
should  be  made  of  full  sizes,  and  there  ought  to  be  a  sufficient  number  of  sizes  to 
accommodate  the  largest  as  well  as  the  smallest  men,  and  due  allowance  should  be 
made  in  the  purchase  for  shrinkage,  which  will  be  great.  These  visitors'  coats 
should  be  made  with  some  regard  for  pattern,  which  makes  an  excellent  impression 
on  the  observer  if  the  physicians  and  surgeons  going  about  the  institution  have  on 
well-made  and  well-fitting  coats,  and  the  contrary  impression  is  made  when  the 
men  have  ill-fitting,  buttonless  coats.  And  this  brings  up  the  question  of  but- 
tons. There  is  no  button,  of  course,  that  will  go  through  the  laundry.  Pearl 
buttons  are  out  of  the  question  for  this  reason.  Tapes  do  not  look  well,  and  physi- 
cians and  surgeons  will  not  tie  them,  but  will  jerk  them  off,  as  they  are  sure  to  get 
in  the  way,  and  there  seems,  therefore,  to  be  only  one  form  of  fastening,  and  that 
is  the  brass  snap  button.  This  button  in  time  mashes  down  in  the  mangle  and 
refuses  to  snap,  and  the  surgeons'  coats  will  finally  gape  open;  but  the  coats  will 
usually  last  about  as  long  as  the  buttons,  and  if  the  buttons  happen  to  wear  out 
first,  they  can  be  renewed  in  the  linen  rooms. 

Both  these  forms  of  hospital  clothing  can  be  purchased  at  almost  any  figure 
we  care  to  pay,  ranging  from  S12  up  to  $24  a  dozen,  and  if  we  patronize  a  reliable 
firm,  or  pick  our  own  material  carefully,  the  $18  or  S20  or  even  S24  coat  will  be 
the  cheaper  in  the  long  run,  as  against  the  inferior  material  that  will  be  put  into  the 
cheaper  coat. 

The  visitor's  mantle  is  rather  a  simple  affair,  and  can  be  made  with  a  yard-wide 
piece  for  the  front,  and  another  for  the  back,  running  practically  straight  from  the 
knee  to  the  shoulder,  leaving  an  opening  at  the  top  merely  large  enough  for  the  head. 
The  larger  these  mantles  are  made,  the  longer  will  they  last,  because,  after  they  have 
been  through  the  laundry  a  few  times,  they  will  tear  easily  in  the  tugging  process 
of  getting  a  tight  one  on.  These  articles  are  worn  by  outside  visitors,  by  visiting 
physicians,  and  students  in  the  operating-rooms,  to  the  end  that  they  may  not 
unsterilize  things  with  their  hands  or  clothing,  and  by  lay  visitors,  parents,  and 
friends  in  the  maternity  and  children's  departments  of  the  institution.     They 


PURCHASE    OF   SUPPLIES  545 

are  by  no  means  expensive,  and  a  good  seamstress  can  make  a  dozen  or  a  dozen  and 
a  half  in  a  day  in  the  linen  rooms,  or  any  good  tailoring  house  will  probably  make 
them  cheaper  than  they  could  be  made  in  the  institution  if  orders  for  a  gross  or 
more  are  given  at  one  time.  They  should  take  about  3  yards  of  yard-wide  goods 
at  the  outside,  even  in  the  larger  sizes,  a  yard  and  a  half  in  front  and  the  same  for 
the  back. 

Uniforms. — Some  institutions  use  cloth  of  the  finer  kinds  for  uniforms  for 
some  of  their  more  conspicuous  employees,  such  as  elevator  men  and  office  boys,  and 
if  these  uniforms  are  of  good  cloth  of  a  lasting  quality,  with  brass  buttons  and  gold 
braid,  they  will  cost  about  $12,  and  there  will  not  be  very  much  saving  at  any  price 
under  that  because  it  will  be  at  the  expense  of  the  quality  of  the  goods.  There 
are  other  employees  of  the  institution  that  must  have  more  serviceable  working 
uniforms,  and  a  very  excellent  cloth  for  these  cheaper  uniforms  is  the  U.  S.  Army 
khaki  or  a  lighter  weight  of  the  same  goods.  The  browns  and  buffs  of  khaki  are 
not  pretty,  but  it  can  be  bought  in  olive  greens  and  the  dull  shades  of  blue.  In  the 
Michael  Reese  Hospital  an  olive  green,  light-weight  khaki  uniform  with  brass 
buttons,  fastened  with  rings  into  worked  button-holes,  and  braid  of  a  slightly 
darker  color,  is  worn  by  orderlies,  elevator  men,  and  the  office  boys.  This  makes 
a  serviceable  uniform  at  a  very  low  prices — about  S3  per  two-piece  suit.  The  trou- 
sers and  sleeves  must  be  made  very  long  to  provide  against  shrinkage,  and  they  will 
be  all  the  better  if  the  ends  of  the  sleeves  and  the  trousers  have  an  extra  hem  so 
that  they  can  be  let  out.     The  shrinkage  is  mostly  in  the  length. 

If  the  men  are  charged  for  these  uniforms  and  required  to  turn  them  in  when 
they  give  up  their  employment,  and  are  also  compelled  to  turn  in  the  old  ones  for 
new  ones,  without  any  additional  price,  they  can  be  kept  in  very  serviceable  and 
presentable  shape.  The  men  will  not  want  to  wear  them  after  they  are  faded  and 
look  badly,  and,  as  they  do  not  have  to  pay  for  the  second  suit,  they  have  no  hesi- 
tancy in  asking  for  a  new  one.  It  is  the  custom  to  give  these  employees  an  order 
for,  say,  three  or  four  suits  of  these  uniforms,  and  then  require  them  to  take  care 
of  them.  They  do  not  fade  very  much,  and  the  direction  of  fading  does  not  leave 
them  with  that  washed-out  look  about  them  so  common  in  the  blue  or  the  cheaper 
overall  patterns. 

The  men  who  do  rough  work,  such  as  the  yard  men,  kitchen  helpers,  garbage 
men,  window  cleaners,  wall  washers,  and  the  like,  can  be  made  to  wear  the  heavier 
patterns  of  brown  khaki,  and  the  floor  men  can  be  put  in  overalls  of  any  presentable 
pattern,  and  they  look  very  much  better  than  will  the  men  who  go  about  the  place 
in  nondescript  clothes,  oftentimes  in  their  shirt  sleeves,  and  with  dirty  shirts  at 
that.  These  overalls  can  be  bought  in  quantities,  and  in  very  good  material,  for 
about  50  rents  per  piece,  or  si  for  the  two-piece  uniform,  and  these  overalls  wash 
very  well,  as  a  rule,  and  especially  it  they  are  washed  without  being  boiled  or 
bleached. 

ENAMELWARE 

The  enamelware  for  the  wards  and  private  rooms  is  of  the  utmost  import- 
ance.   The  principal  item  is  the  bed-pan,  the  other  items  being  chiefly  urinals, 

male  and  female,  and  the  care  of  these  two  utensils  is  secondary  only  t<>  the  kind 
of  utensils  themselves. 

Bed-pans  have  been  a  problem  ever  since  the  days  of  the  old  yellow  earthen- 
ware shovel-shaped  bed-pan  of  our  grandfathers.  There  is  only  one  made  that  jus- 
tifies  ii  lent  ion.  and  that  is  the  "Perfection"  bed-pan,  made  by  Meinecke<  !ompany 
of  New  York.     The  price  of  this  pan  is  something  more  than  S3  each,  even  in  very 


546  OPERATION    OF   THE    HOSPITAL 

large  quantities,  and,  aside  from  the  monopolistic  rights  of  this  utensil,  the  price 
of  $1  would  allow  a  handsome  margin  of  profit.  Its  chief  point  of  advantage  is 
the  ease  with  which  patients  are  accommodated  upon  it,  whether  they  lie  down  or 
are  in  a  reclining  position.  Then,  again,  the  contents  do  not  spill  readily,  it  cleans 
easily,  and  is  carried  from  one  place  to  another  with  facility. 

There  is  a  small  bed-pan,  known  as  the  Eureka,  a  few  of  which  should  be 
kept  in  the  hospital  for  special  cases  and  convalescents  who  can  move  themselves 
about  easily. 

Urinals  are  usually  made  of  enamel  for  institution  work  because  of  the  immense 
breakage  when  they  are  made  of  glass.  Male  urinals  are  very  difficult  to  clean, 
and  if  they  are  not  carefully  cleaned  the  fact  is  not  manifest  except  by  the  odor, 
because  of  the  difficulty  of  seeing  inside  of  them.  There  is  a  glass  male  urinal  made 
that  must  come  more  into  vogue,  largely  because  it  is  graduated  on  the  outside, 
and  the  amount  of  urine  can  be  accurately  measured  without  pouring  it  into  another 
vessel.  This  is  a  good  deal  of  saving  of  time,  especially  on  the  medical  wards, 
and  among  private  patients  suffering  from  diabetes,  Bright's  disease,  and  other 
kidney  involvement.  Their  disadvantage,  of  course,  is  that  they  cost  a  good  deal 
and  break  easily. 

Racks  for  the  care  of  bed-pans  and  urinals  are  almost  as  important  a  consid- 
eration as  the  vessels  themselves.  There  is  no  rack  made  that  answers  the  purpose 
intended,  and  shelves  set  firmly  an  inch  away  from  the  wall,  so  that  they  can  be 
kept  dry  and  clean,  are  the  best  receptacles  for  both  of  these  utensils.  Usually 
speaking,  the  vessels  are  put  away  wet  after  being  cleaned,  and  if  the  shelves  are 
covered  with  anything  at  all,  it  should  be  with  the  stain  preparation  used  for  the 
laboratory  tables,  the  formula  for  which  is  given  in  the  section  on  Pathology, 
Or  they  may  be  kept  in  a  metal  cabinet,  such  as  is  shown  elsewhere,  provided  there 
is  ventilation  in  the  cabinet. 


IRRIGATORS  AND  GLASSWARE 

Irrigators,  large  or  small,  whether  intended  for  the  operating-room  or  for  con- 
tinuous irrigation  at  the  bedside  of  the  patient,  or  for  the  service  of  dressing-rooms, 
are  mostly  of  glass.  They  are  carried  on  stands  high  up,  and  in  some  cases  on  carts, 
and  they  are  nearly  always  carried  so  high  that  one  cannot  see  into  them,  and  they 
are  more  than  likely  to  be  dirty,  or  at  least  carry  a  sediment,  unless  they  are  of 
clear  glass,  so  that  the  least  particle  of  dirt  will  show  through.  Then  again,  if 
they  are  of  glass,  the  reading  of  the  thermometer  will  be  easy  without  its  removal. 

While  we  are  on  this  subject  of  irrigators,  it  may  be  well  to  discuss  a  new  method 
of  maintaining  temperature  in  irrigating  water,  devised  by  Dr.  L.  A.  Greensfelder, 
of  the  surgical  staff  of  the  Michael  Reese  Hospital.  This  form  of  irrigator  is 
nothing  more  nor  less  than  an  ordinary  quart  or  half-gallon  thermos  bottle.  Figure 
193  shows  one  of  these  thermos  irrigators,  the  method  of  operation  being  as  fol- 
lows: There  is  a  rubber  cork  made  to  fit  tight,  with  two  round  holes  for  the  glass 
tubing;  there  is  a  fastening  on  each  side  at  the  bottom  of  the  bottle,  with  a  wire  or 
string  drawn  through  for  fastening  the  bottle  to  the  head  of  the  bed  or  to  a  raised 
standard.  The  rubber  tubing  is  attached  to  the  glass  tubing,  as  shown  in  the  illus- 
tration, and  the  bottle  is  filled  and  hung  bottom  side  up.  With  the  ordinary  drop 
method  of  continuous  irrigation  the  quart  thermos  bottle  will  last  about  three 
hours,  and  with  some  operators  four.  The  water  in  the  bottle  will  not  vary  more 
than  2  degrees  in  temperature  in  the  time  necessary  to  empty  it,  and  by  its  use  we 
do  away  with  the  necessity  to  surround  the  ordinary  glass  irrigator  with  hot-water 


PURCHASE    OF   SUPPLIES 


547 


bottles,  or  to  maintain  temperature  by  a  thermo-rcgulator  or  some  other  device, 
such  as  hot  packs,  hot  sand-hags,  and  the  like. 

An  eleetrotherm  is  offered  for  irrigating  purposes,  but  an  even  temperature 
cannot  be  maintained  without  the  closest  watching.  Besides,  they  are  more  costly 
than  the  thermos  bottle,  as  they  are  very  frequently  out  of  order,  whereas  the  ther- 
mos bottle  is  always  ready  for  work,  liar- 
ring  a  fall  sufficient  to  break  the  glass 
In  title  inside.  This  does  not  happen  very 
often,  and  manufacturers  of  thermos 
bottles  charge  about  $2.50  for  fitting 
them  with  a  new  bottle  when  one  is 
broken.  The  eleetrotherm  costs  nearly 
twice  as  much  as  the  thermos  bottle,  and 
will  burn  out  so  much  more  frequently 
than  the  thermos  is  broken  that  there  is 
hardly  a  comparison  financially  between 
the  two  pieces  of  apparatus. 

For  purposes  of  cleanliness,  enema 
points,  irrigating  points,  connecting  points 
for  rubber  tubing  and  female  catheters 
should  be  made  of  clear  glass.  If  such 
dressing  as  packing,  iodoform,  and  com- 
bination gauze,  nail-brushes  for  operat- 
ing- and  dressing-rooms,  sand  soap,  and 
gloves  are  kept  in  glass  jars,  cleanliness 
and  asepsis  are  more  likely  to  be  observed 
than  if  the  containers  for  these  items  are 
made  of  material  that  will  not  allow  of 
complete  inspection  at  all  times.  Some 
day  some  one  will  make  of  glass  a  liquid- 
soap  container  for  operating-  and  dressing- 
rooms,  one  that  will  release  a  sufficient 
amount  of  soap  to  serve  the  purpose  with- 
out   wasting    it,    and    that    will    not   get 

clogged  and  refuse  to  work  on  every  occasion.  There  is  no  such  piece  of 
apparatus  made  at  the  present  time.  Those  that  are  to  be  had  have  what  the 
salesmen  call  "good  talking  points,"  but  uniformly  they  lack  good  working  points. 


-The  Grcensf older   thermos   irri- 
gator. 


MISCELLANEOUS   RUBBER  SUPPLIES 

Sheets  and  Blankets.— The  rubber  sheet  is  much  smaller  than  the  blanket; 
the  blanket  is  intended  to  cover  the  whole  of  the  bed,  whereas  the  rubber  sheet  is 
intended  to  cover  the  space  ordinarily  covered  by  the  draw  sheet,  that  is.  under 
the  body  or  trunk  of  the  patient,  to  save  the  mattress  and  to  catch  whatever 
secretions  may  emanate  from  the  body.  Both  these  articles  must  meet  the  same 
general  requirements;  that  is,  they  must  not  tear  easily,  and  they  must  preserve 
their  integrity,  not  only  in  contact  with  the  bodily  secretions,  but  in  the  presence 
of  acids  and  nils  especially  the  latter— and  drugs  generally.  There  seems  to  he 
no  rubber  sheeting  made  that  will  stand  up  in  the  presence  of  oil:  the  reason  for 
this  is  that  the  oil  enters  into  combination  with  the  resin  of  the  rubber,  vulcan- 
izing it,  causing  it  to  harden,  curl  up,  and  peel  off.     The  cruder  the  rubber  in  these 


548  OPERATION    OF   THE    HOSPITAL 

goods  and  the  less  refined  the  more  resin  there  is  left  in  them,  and,  as  it  costs 
money  to  take  resin  out  of  rubber,  these  excess  resin  rubbers  are  cheap  in  pro- 
portion as  the  amount  of  sulphur  is  great. 

The  price  of  rubber  is  not  always  a  test  of  its  virtue,  but  honest  firms  that  fix  the 
values  of  their  goods  on  honest  conditions  will  ask  more  for  pure  rubber  than  for 
indifferent  or  poor  rubber,  and,  so  far  as  we  know,  there  is  only  one  test,  and  that 
is  actual  experience.  Some  of  us  have  bought  rubber  sheeting  as  low  as  70  cents 
per  yard,  and  have  paid  as  high  as  $2.50  per  yard  within  the  last  few  years.  As  a 
general  rule,  and  if  the  dealer  has  been  honest,  the  $2.50  goods  give  better  service 
in  proportion  to  the  money  invested  than  the  poorer  goods;  in  other  words,  a  good 
sheet  at  $2.50  per  yard  will  last  longer  than  three  or  four  of  the  poorer  kinds, 
assuming  that  the  poorer  ones  have  been  used  consecutively,  one  after  the  other, 
by  the  side  of  the  good  sheeting,  and  at  the  same  kind  of  service. 

It  may  be  doubted  whether  much  depends  on  the  color  of  rubber  sheeting. 
Some  dealers  who  make  a  good  maroon  sheet  claim  virtues  for  that  color.  Some 
who  make  a  white  sheet  claim  that  the  absence  of  coloring  dyes  makes  for  purity, 
and  that,  having  no  chemical  dyes,  the  rubber  itself  lasts  longer  than  in  the  other 
colors.  There  are  other  makers  who  believe  black  rubber  to  be  the  best.  There 
is  not  very  much  to  these  claims,  the  known  integrity  of  the  makers,  based  upon 
past  experience,  being  the  best  guide.  There  is  just  now  a  sheeting,  maroon  in 
color,  at  $1.10  per  yard  in  quantities  of  500  yards;  this  includes,  of  course,  consider- 
able discounts  from  list  prices,  based  on  the  size  of  not  only  the  one  order,  but  all 
other  orders  given  at  the  same  time  for  other  classes  of  rubber  goods.  Meinecke, 
of  New  York,  sells  the  best  rubber  sheeting,  and  at  their  best  prices  it  will  be  found 
most  economic.  Of  course  there  is  a  great  deal  in  the  quality  of  the  cloth  used  in 
rubber  sheeting,  and  this  quality  can  be  tested  by  its  tearing  properties  at  the  time 
of  purchase,  and  if  the  rubber  itself  is  of  such  quality  that  it  will  not  break  or  curl 
the  cloth  itself  will  retain  its  strength  very  well. 

There  is  on  the  market  a  sheeting,  rubber  on  one  side  and  cloth  on  the  other, 
that  sells  for  the  ridicuously  low  price  of  35  cents  per  yard.  It  may  be  used  for 
protective  pillow-cases  or  for  sand-bags,  but  such  use  will  be  very  inconsequential 
and  hardly  worth  while.  It  is  much  better  not  to  have  a  poor  rubber  sheeting  about 
the  premises,  because  there  is  great  danger  of  carrying  infections  in  the  cloth  side, 
which  cannot  be  cleaned  readily,  and,  in  any  event,  urines  and  other  stains  soon 
render  the  goods  unfit  for  use. 

Just  here  we  might  mention  another  substitute  for  rubber  sheeting — namely, 
a  heavy  canvas  treated  with  a  tar-oil  preparation  to  make  it  waterproof.  It  is 
ill-smelling  stuff  when  brand  new,  and  does  not  improve  with  an  admixture  of 
urine  and  feces.  If  heat  sterilization  is  attempted  the  surface  preparation  becomes 
sticky  and  the  whole  sheet  runs  into  an  impossible  mass. 

Other  Rubber  Goods. — There  are  other  rubber  goods  that  enter  into  the  equip- 
ment of  the  operating-  and  dressing-rooms  and  the  wards  of  the  institution — the 
Burr  bath  sheet  for  tubbing  typhoids,  the  Kelly  pad,  used  mostly  for  bed  dressings, 
invalid  rings,  water-  and  ice-bags,  tubing,  bandages,  and  catheters. 

It  goes  without  saying  that  these  goods  must  be  subjected  to  acids  and  dressings 
of  various  sorts,  and  to  whatever  oils  may  be  used  in  connection  with  them — such, 
for  instance,  as  the  enema  oils — and  for  the  same  reason  that  oils  destroy  sheeting 
and  blankets,  they  also  destroy  these  other  classes  of  rubber  goods. 

The  principal  thing  to  guard  against  in  the  use  of  ice-bags  and  caps,  bath  caps, 
and  rubber  urinals  is  weak  joints  and  exposed  points  that  are  not  reinforced.  It 
will  not  do  to  assume  that,  because  a  water-bag  seems  to  be  reinforced  on  the 


PURCHASE    OF    SUPPLIES  ,549 

outside,  that  it  must  necessarily  be  reinforced  inside,  and,  as  in  many  items  of 
hospital  supplies,  we  must  in  a  large  way  trust  to  the  honor  of  the  manufacturer 
for  the  quality  of  the  goods. 

A  third  class  includes  the  tubing  of  various  sorts,  including  soft  catheters  and 
French  catheters,  made  stiffer  for  prostatic  passage,  colon  and  rectal  tubes,  ice- 
coils  for  head  and  abdomen,  and  pure  gum  drainage  tubing. 

A  fourth  class  of  rubber  goods  may  be  made,  which  includes  Esmarch  bandages, 
for  which  there  is  now  oftentimes  a  substitute  in  the  shape  of  a  rubber  bandage,  and 
a  heavy  rubber  tubing  is  used  for  the  same  purpose  with  quite  as  much  success. 

There  is  very  little  to  be  said  about  catheters  of  various  sorts.  Almost  any  of 
those  offered  for  sale  are  adequate  for  the  purposes  intended.  Some  of  them  are 
made  out  of  better  rubber  than  others,  and  consequently  stand  up  under  steril- 
ization better,  and  they  cost  a  little  more  than  the  poorer  quality. 

There  is  a  good  deal  to  be  said  about  colon  and  rectal  tubes.  There  is  a  diver- 
sity of  opinion  among  medical  men  whether  the  high  rectal  tube  and  the  colon 
tube  always  penetrate  their  full  length,  and  we  have  seen  many  x-ray  pictures 
taken  of  bismuth-lined  colon  tubes  that  seemed  to  pass  with  ease  straight  up  the 
canal,  but  the  picture  showed  they  curled  upon  themselves.  It  is  not  an  easy  matter 
to  determine  just  the  proper  stiffness  desirable  in  a  colon  tube;  if  it  is  stiff  enough 
to  guide  straight  up  the  canal,  it  is  oftentimes  hard  enough  to  actually  perforate  the 
intestinal  wall,  and  this  has  been  done.  If  it  is  soft  enough  for  safety  it  is  very  much 
more  than  likely  to  curl  on  itself,  and,  after  all,  the  introduction  of  a  high  rectal  or 
colon  tube  is  a  matter  of  deftness  and  technic,  rather  than  a  question  of  the  hardness 
or  softness  of  the  tube. 

The  cleaning  of  these  tubes  is  another  very  important  matter.  Of  course, 
every  colon  tube  when  withdrawn  is  alive  with  micro-organisms;  some  of  these 
are  pathogenic,  and  many  of  them  are  not  so  under  any  but  exceptional  conditions, 
but  a  colon  tube  might  well  be  an  agent  for  carrying  an  infection  from  one  patient 
to  another,  and  we  have  knowledge  of  a  whole  chain  of  colitis  cases  without  any 
apparent  reason,  excepting  the  possible  infection  of  the  tubes  used  for  the  several 
patients.  Generally  speaking,  there  is  no  lack  of  effort  on  the  part  of  nurses  in  the 
cleansing  of  their  tubes.  The  question  is  wholly  one  of  method.  In  some  insti- 
tutions the  tubes  are  boiled  after  each  using.  In  other  institutions  they  are 
cleaned  with  hot  water  and  soap,  and  are  then  soaked  in  5  per  cent,  carbolic  acid; 
elsewhere  they  are  dipped  in  1  :  1000  bichlorid  solution  after  cleaning  with  hot 
soapsuds.  We  have  at  times  investigated  these  various  methods,  and  the  lal  (ora- 
tory has  found  too  often  that  cultures  could  be  grown  from  colon  tubes  that  had  Urn 
apparently  well  cleaned  and  dipped  in  5  per  cent,  carbolic  acid,  anil  in  a  few  instances 
cultures  have  been  grown  where  the  tubes  had  been  dipped  in  the  bichlorid,  but 
there  will  be  no  cultures  after  the  tube  has  been  boiled,  although  boiling  is  hard 
on  the  tubes.  An  objection  to  boiling  is  the  disintegration  of  the  tube,  and  tubes  of 
the  very  best  rubber  will  not  stand  up  for  more  than  three  or  four  boilings,  and  even 
before  that  time  they  become  so  soft  that  they  are  almost  useless  for  the  purposes 
intended.  So  far  as  we  know,  the  only  solution  of  the  question  is  to  replace  the 
tubes  as  often  as  necessary  and  to  boil  them  well  as  long  as  they  last.  The  reason 
why  the  tube  dipped  in  bichlorid  or  carbolic  acid  will  sometimes  make  cultures  is 

because  occasionally  the  inside  of  the  tube  will  catch  :i  quantity   of  mucus  I'r the 

intestinal  canal,  and  this  mucus  in  the  presence  of  carbolic  or  bichlorid  will  often- 
times harden  and  encapsulate  the  micro-organism,  and  will  act  as  a  protecting 
shield  against  the  invasion  of  the  sterilizing  fluid. 

Of  course,  it  goes  without  saying  that  all  colon,  rectal,  and  stomach-tubes  must 


550  OPERATION    OF   THE    HOSPITAL 

be  open  at  the  end  as  well  as  at  the  sides,  and  that  the  end  opening  must  be  as  large 
as  the  lumen  of  the  tube  itself,  so  that  no  secretion  may  gather  in  force. 

Care  of  Rubber  Tubing  and  Catheters. — The  best  way  to  keep  these  articles 
is  in  a  thoroughly  dry  state,  immersed  in  talcum  powder.  If  they  can  be  hung 
straight  in  long  glass  tubes,  sealed  at  one  end  and  well  corked  at  the  other,  the 
form  will  be  best  preserved. 

The  purchase  and  care  of  rubber  gloves  are  taken  up  in  detail  in  the  section 
on  Operating-room  Technic. 

Purchase  of  Consumable  Supplies 
meats  and  fish 

Whatever  may  be  said  about  the  ethics  of  an  economic  situation  in  this  country 
that  has  permitted  the  control  of  the  meat  industry  to  fall  into  the  hands  of  a  few 
corporations,  it  must  be  admitted  that  some  very  wholesome  results  have  followed 
in  consequence  of  that  control.  When  there  were  slaughter-houses  operated  by  in- 
dividual butchers  on  the  outskirts  of  every  village,  town,  and  city  there  could  be 
no  control  over  the  slaughter  and  preparation  of  meats  as  human  food.  Any  ade- 
quate inspection  was  out  of  the  question,  unless,  indeed,  there  were  an  inspector  for 
every  slaughter-house,  whose  duty  it  would  be  to  inspect  not  only  the  meats  after 
they  were  killed,  but  the  meat  animals  on  the  hoof  and  the  conditions  for  the  care 
of  the  meat  after  it  was  killed.  Those  were  the  days  of  trichina  in  hogs  and  the 
insidious  forms  of  ptomains  in  beef,  mutton,  and  veal.  Again,  the  meat  industry 
has  grown  into  so  compact  and  gigantic  an  institution  that  the  public  has  become 
aroused  to  a  necessity  for  very  strict  regulations,  to  the  end  that  national,  state, 
and  municipal  inspectors  are  in  control  nowadays  of  the  meat  output,  especially 
that  part  of  it  that  has  its  home  in  Chicago's  packing  town,  and  this  inspection  sifts 
pretty  thoroughly  the  good  from  the  bad  and  indifferent  stock  importations  to  the 
slaughter-house  district.  Huge  rendering  plants  that  eventuate  in  soap-works 
have  grown  up  about  Packing  Town  for  the  utilization  of  diseased  stock  that  for- 
merly was  sold  as  food. 

Meat  for  institution  use  now  comes  either  from  the  Chicago  stock-yards  under 
a  sufficient  protection  to  guarantee  its  wholesomeness,  or  from  local  slaughtering- 
houses,  still  maintained  in  a  few  places,  but  whose  sanitation  and  hygienic  conditions 
can  be  made  a  matter  of  personal  inspection  by  the  institution  administration. 
The  question  of  diseased  meat,  therefore,  has  become  a  negligible  quantity,  and  in 
considering  meat  we  need  only  contemplate  the  standards  of  those  qualities  above 
suspicion. 

Beef  is  the  most  important  meat  that  we  have  to  buy,  and  it  comes  to  us  in 
one  of  three  states — either  fresh,  that  is,  immediately  after  it  has  been  killed,  and 
before  rigor  mortis  takes  place,  and  before  the  animal  heat  has  left  it;  chilled  meat, 
or  that  which  has  been  kept  in  cold  storage  above  the  freezing-point  for  hours  or 
days,  or  even  weeks,  until  withdrawn  for  use;  and  frozen  meat,  or  that  which 
has  been  frozen  hard  and  kept  so  for  varying  lengths  of  time. 

In  the  public  campaigns  that  have  followed  occasional  uprisings  against  pack- 
ing-house methods  a  great  deal  has  been  learned  about  meats  and  their  preparation. 
One  of  these  things  is  that  meat  ought  to  be  immediately  chilled  after  it  is  killed 
to  prevent  either  chemically  fermentative  changes  or  bacterial  growths,  and 
unless  we  have  in  the  institution  abundant  facilities  for  chilling  our  own  meats 
before  bringing  them  to  use,  they  ought  not  to  be  purchased  fresh  and  unstiffened. 


PURCHASE    OF   SUPPLIES  551 

Freshly  killed  meat  has  a  brown,  smoky  look  about  it,  is  soft  and  pulpy.  If  it 
is  cooked  at  that  stage  it  becomes  tough  and  stringy,  and  is  not  regarded  as  a  good 
meal  from  the  epicurean  standpoint,  however  nutritious  it  may  be  in  contact  with 
the  digestive  apparatus. 

Frozen  meat  has  a  peculiarly  marble-like  appearance;  the  division  lines  between 
the  fat  and  the  lean  are  clear  cut  and  distinct.  The  fat  immediately  next  to  the 
lean  is  very  white,  and  the  lean  has  that  peculiarly  handsome,  bright-red  appear- 
ance which  we  recognize  as  a  good  healthy  meat  color.  The  objection  to  frozen 
meat  is  that  there  are  difficulties  in  the  way  of  thawing  it  out  and  of  cooking  it.  In 
tropical  countries  it  is  almost  a  dangerous  thing  to  attempt  to  cook  frozen  meats, 
because  it  not  infrequently  happens  that  before  the  meat  is  put  into  the  chilling 
rooms  flies  have  been  allowed  to  blow  it,  and  it  has  become  infected  with  bacteria, 
some  of  which  are  more  or  less  poisonous  in  character;  the  freezing  process  makes  it 
impossible  for  these  bacteria  to  become  active  or  to  reproduce  and  thus  to  form 
toxins;  when  this  frozen  meat  is  put  upon  the  fire,  especially  if  it  is  put  in  a  slow 
oven,  as  is  many  times  done  for  the  purpose  of  thawing  it,  the  bacteria  seem  to 
spring  into  activity,  and,  even  before  the  meat  is  thawed,  it  is  sufficiently  infected 
with  bacteria  and  their  toxic  products  to  produce  ptomain-poisoning.  The  only 
proper  way  to  thaw  frozen  meat  for  cooking,  and  it  is  a  poor  way  at  best,  is  to  thaw 
it  out  in  cold  water,  and  then  to  put  it  on  the  fire  to  cook  in  whatever  way  it  is 
intended  to  be  used,  whether  steak,  roast,  or  boiled. 

The  best  form  of  meat  to  be  used  is  that  which  has  been  chilled  and  main- 
tained at  a  temperature  higher  than  the  freezing-point.  Chilled  meat  can  be 
readily  distinguished  by  those  who  are  accustomed  to  handling  it  by  the  fact  that 
the  fat,  especially  that  nearest  to  the  lean,  is  pinkish  in  color,  which  indicates  that 
the  meat-juices  have  run  across  to  the  fatty  tissues. 

Diseased  Meats. — Meats  offered  for  sale  in  this  country  to-day  are  tolerably 
free  from  suspicion  of  disease,  and,  fortunately,  most  of  these  diseases  can  be  readily 
detected,  either  before  the  animal  is  killed  or  without  the  aid  of  the  microscope 
afterward.  About  the  only  beef  disease  worthy  of  consideration  is  tuberculosis, 
and  this  disease  is  usually  expressed  in  the  form  of  the  so-called  lumpy  jaw,  which 
is  easily  detected  during  the  life  of  the  animal,  and  is  sufficient  cause  for  condemna- 
tion by  the  inspectors,  or  in  the  form  of  enlarged  and  often  purulent  glands.  The 
so-called  "measles"  in  beef  meat  is  due  to  the  presence  of  a  micro-organism  known 
as  the  Taenia  saginata,  and  this  measles  disease  is  very  easily  detected  by  making 
a  fresh  cut  of  meat  at  almost  any  point.  The  measles  blotches  are  about  the  size 
of  a  pea,  whitish  in  color;  within  their  areas  reside  the  parasites;  this  meat  has 
harmful  toxic  properties. 

Pork  meat  has  two  diseases — trichina,  which  unfortunately  must  be  seen  under 
the  microscope,  and  the  so-called  Taenia  solium.  Trichinosis  is  a  disease  that  seems 
to  be  very  rapidly  disappearing,  and,  indeed,  confined  to  hogs  fed  on  decomposing 
animal  food  or  on  fermented  products,  such  as  the  distillery  outputs;  the  Ta?nia 
solium  can  be  detected  in  hog  meat  with  the  naked  eye,  and  is  identical  in  appear- 
ance with  the  "measles"  of  beef. 

Sometimes  mutton  is  affected  with  the  so-called  hydatid  micro-organism,  but 
it  is  so  infrequent  and  so  difficult  to  find  that  no  amount  of  carefulness  will  protect 
mutton  caters  against  it.  Occasionally  also  mutton  is  affected  by  the  tetanus 
bacillus,  but  infrequently;  and,  without  doubt,  this  micro-organism  is  a  negligible 
quantity  in  discussing  the  merits  (if  mutton  for  eating  purposes. 

The  only  precaution  necessary  in  the  purchase  of  veal  is  to  be  sure  it  is  not  too 
young.     There  are  peculiar   chemic  constituents   in   the   meat   of  all  very  young 


552  OPERATION   OF   THE   HOSPITAL 

animals  that  make  it  unfit  for  food,  but  the  results  of  eating  too  young  meat  are 
usually  not  severer  than  diarrhea  or  some  slight  gastro-intestinal  disturbance. 

Choice  of  Healthy  Meats. — There  is  no  institution  so  small  but  what  the  great- 
est possible  economy  would  be  practised  by  the  purchase  of  whole  carcasses,  and 
if  it  is  a  small  institution,  the  expense  of  putting  in  an  ice-box  and  the  purchase  of 
ice  to  cool  it  will  be  more  than  repaid  in  economic  purchase  of  whole  carcasses,  from 
which  selections  may  be  made  for  various  feeding  purposes  in  the  institution. 
Oftentimes  when  small  cuts  are  bought  at  the  corner  butcher  shop,  meat  that  has 
cost  20  or  30  cents  per  pound  will  be  used,  where  a  piece  costing  only  half  as  much 
might  serve  quite  as  good  if  not  a  better  purpose;  where  one  has  a  whole  carcass  to 
choose  from,  just  the  right  meat  for  the  purpose  can  be  picked.  Of  course,  insti- 
tutions that  have  their  own  ice  plant  ought  to  keep  a  number  of  carcasses  of  various 
animals  hanging  all  the  time  in  a  temperature  a  little  above  freezing,  and  then  a 
very  fine  selection  of  cuts  can  be  made  for  the  various  institution  purposes. 

It  is  not  economy  to  buy  heavy  cuts  of  meat.  Small  animals  with  small  bones, 
like  the  heifer  or  the  young  steer,  or  the  small  fat  cow,  is  a  much  more  economic 
form  of  meat  than  the  big-boned  ox  with  large  deposits  of  fat.  Old  animals  espe- 
cially are  uneconomic,  because,  if  they  are  thin,  the  bone  weighs  too  much,  and  if 
they  are  fat,  there  is  too  much  waste  in  the  chunks  of  fat  unevenly  distributed  and 
not  available  for  food.  Bull  meat,  so  often  sold  for  that  of  the  steer,  and  the 
character  of  which  is  detected  by  the  stringiness  of  the  lean  and  the  absence  of  sur- 
face fat,  is  oftentimes  an  economic  meat  to  buy  for  stews  for  the  help  or  for  soup 
meat.  It  is  always  much  cheaper  than  ox  or  cow  meat.  There  is  no  economy  in 
buying  large  ribs,  because  the  waste  is  very  great  both  in  bone  and  fat.  "Second" 
ribs,  that  weigh  an  average  of  35  pounds,  and  that  cost  1  cent  or  even  2  cents  a 
pound  more  than  the  "firsts,"  are  cheaper  than  the  "firsts,"  which  weigh  60  or  75 
pounds. 

The  only  other  animal  in  which  there  is  much  choice  in  the  hung  animal  is  the 
hog,  and  the  same  principles  apply  as  in  beef.  The  small  young  hog  can  be  very 
much  more  advantageously  used  because  of  the  smaller  amount  of  fat  and  the 
smallness  of  the  bone,  and  the  smaller  breeds  of  hogs  are  better  for  the  same  reason. 

The  Cutting  of  Meats. — It  will  be  rather  useless  for  us  to  go  into  the  question 
of  the  cutting  of  meats,  because  that  field  is  covered  amply  in  the  works  on  dietary 
and  digestion,  and  we  need  concern  ourselves  at  this  point  only  with  the  economic 
phase  of  the  question.  There  is  more  to  the  cutting  of  meat  than  the  casual  ob- 
server would  believe,  and  a  careful  butcher,  who  thoroughly  knows  his  business, 
and  one  especially  who  knows  about  the  cooking  of  meats,  can  cut  his  pieces  so  that 
some  of  the  very  cheap  parts  can  be  made  to  masquerade  as  fine  cuts;  this  is  not 
a  fraud,  because  oftentimes  the  cheaper  cut  of  meat  has  the  more  nutrition  in  it;  for 
instance,  a  sirloin  is  well  known  to  have  a  higher  nutritive  value  than  a  tenderloin, 
and  yet  the  sirloin  is  the  cheaper.  There  are  many  people  who  from  choice  select 
the  round,  especially  the  inside  of  the  upper  thigh,  in  preference  to  any  other  cut, 
and  if  the  fiber  bundles  of  a  small  round  steak  are  divided  either  by  a  knife  or 
chopper  the  steak  can  be  made  as  tender  and  delicate  as  the  finest  cut  taken  else- 
where. There  is  an  art  in  the  cutting  of  meat,  and  one  of  the  coarsest  cuts  of  the 
animal,  in  the  hands  of  an  artistic  butcher  and  an  artistic  steward,  can  be  made  to 
surpass  in  delicacy  and  flavor  even  the  finest  cuts  in  the  hands  of  some  one  who  does 
not  know  how  to  cut  or  prepare  them,  and,  after  all,  what  is  called  economy  in  the 
cutting  of  meats  is  nothing  more  nor  less  than  the  careful  cutting  of  the  coarser 
parts  to  make  them  appetizing,  so  that  they  will  masquerade  for  choicer  and  more 
expensive  cuts.     Some  extremely  interesting  studies  on  the  subject  of  waste  in 


PURCHASE    OF   SUPPLIES  553 

food  animals  have  been  made  at  the  Chicago  packing  houses,  when  the  saving  of 
even  an  extra  drop  of  blood  from  each  animal  slaughtered  in  the  course  of  a  year 
may  run  into  hundreds  of  dollars.  For  instance,  it  has  been  found  that  in  the 
average  steer  marketed  there  is  122  per  rent .  of  bone  w  hicb  is  of  pracl  ically  no  value 
as  food;  while  in  the  average  cow  there  is  26  per  cent,  of  useless  bone,  and  in  the 
calf  only  16  to  18  per  cent.,  according  to  the  age  of  the  animal.  From  these 
figures  we  may  judge  that  the  careful  selection  of  meats  may  mean  a  great  saving 
in  the  course  of  the  year. 

Poultry. — In  the  Michael  Reese  Hospital  a  study  was  made  covering  a  long 
period  of  time  concerning  the  waste  in  poultry.  About  25  per  cent,  of  poultry  of 
all  kinds — chickens,  ducks,  and  turkeys— were  found  to  be  made  up  of  waste  pro- 
ducts—heads, feet,  feathers,  and  intestines.  It  was  also  found,  however,  that 
nearly  50  per  cent,  of  this  waste  was  made  up  of  necks  and  feet  that  are  usually 
thrown  away;  and  of  the  gizzards,  livers,  and  hearts,  all  of  which  are  available  with 
little  trouble  of  cleaning,  for  making  broths  for  special  diet  cases. 

The  Purchase  of  Fish. — Fish  being  a  cold-blooded  animal,  the  question  of 
setting  or  ripening  after  the  animal  heat  is  gone  does  not  obtain,  and,  without  any 
doubt,  the  delicacy  of  fish  as  a  food  depends  upon  its  freshness.  There  are  many 
persons  who  find  fish  a  delicious  food  when  cooked  over  the  camp-fire  immediately 
after  it  is  caught,  and  these  same  people  dislike  fish  intensely  as  it  is  purchased  on 
the  market,  no  matter  how  much  better  it  is  cooked  at  home. 

As  we  buy  fish  on  the  markets  to-day  we  must  understand  that  there  are  definite 
sources  of  supply,  and  we  must  take  into  account  the  long  hauls  in  transit.  For 
instance,  nearly  all  the  halibut  that  is  used  in  this  country  comes  from  the  Pacific 
coast,  a  little  of  it  from  outside  Vancouver  Island,  but  most  of  it  from  as  far  north 
as  Alaska,  especially  about  Baronoff  Island;  some  of  the  halibut  comes  from  about 
Newfoundland,  especially  that  sold  in  the  east.  Halibut  is  usually  caught  by  the 
natives,  and  thrown  into  the  holds  of  the  fish  vessels  and  packed  in  ice,  and  in  that 
way  is  transported  to  either  Seattle  or  San  Francisco  on  the  Pacific,  or  New  Eng- 
land towns  on  the  Atlantic  coast,  and  thence  goes  by  land  to  the  points  of  destina- 
tion. 

Fresh  halibut  and  fresh  cod  come  practically  from  the  same  neighborhoods,  and 
are  brought  to  market  in  the  same  way  and  in  about  the  same  length  of  time. 

Fresh  salmon  is  a  vastly  different  fish  from  that  caught  and  canned  on  the 
Pacific  coast,  as  the  "runs"  go  up  the  streams  to  spawn.  The  fresh  salmon  put 
on  the  market  is  not  the  spawning  member  of  the  family;  it  is  a  vastly  superior 
fish. 

The  other  fish,  such  as  lake  trout,  white  fish,  red  snapper,  sea  bass,  and  the  like 
all  depend  for  their  flavor,  delicacy,  and  attractiveness  on  the  shortness  of  time 
they  have  been  out  of  the  water. 

Halibut  is  the  most  economic  fish  to  buy — the  head  is  cut  off  when  it  is  caught . 
it  has  practically  no  intestines  or  fins,  and  its  bones  are  confined  to  the  spine,  so 
there  is  no  waste  to  speak  of.  In  other  fish  there  is  a  varying  loss  of  weighl  in 
heads,  tails,  fins,  and  intestines,  and  this  waste  ought  to  be  considered  in  the 
purchase. 

The  Purchase  of  Canned  Fish. — In  buying  canned  fish  two  considerations  must 
always  be  uppermost:  first,  the  character  of  the  fish  for  packing  purposes,  and  the 
medium  of  preservation.  There  are  two  kinds  of  fish  packed — the  acid  fish,  like 
Bismarck  herring,  packed  in  vinegar,  and  the  oily  fish,  packed  in  their  own  oil, 
like  salmon,  or  with  other  oils  added,  like  sardines.  Acid-packed  fish  are  liable 
to  be  highly  injurious,  because  the  acid  corrodes  the  tin  of  the  can,  forming  a  tin 


554  OPERATION    OF   THE    HOSPITAL 

salt;  these  fish  are  usually  packed  with  a  tin  plate  of  a  silvery  color  just  under  the 
head  of  the  can  and  soldered  to  it;  if  the  plate  is  separated  from  the  head,  the 
contents  are  quite  likely  to  be  dark  colored  and  impregnated  with  the  harmful 
tin  salts.  All  acidyfish  should  be  packed  in  enamel  or  glass  cans.  There  is  hardly 
any  danger  of  this  kind  with  oil-packed  fish,  and  there  is  much  added  nutrition 
in  the  oils  themselves. 

Salmon  is,  of  course,  the  stand-by  in  canned  fish  for  institution  purposes  and 
an  excellent  article  of  food.  Fortunately,  salmon  are  packed  in  very  few  large 
canneries  on  the  North  Pacific  coast  under  the  eye  of  very  watchful  government 
inspectors.  The  labor  at  the  canneries  is  usually  Chinese,  the  cleanest  labor  to 
handle  foods  in  the  world ;  the  methods  of  processing  are  not  filthy  at  the  worst, 
and  under  present-day  government  supervision  the  work  is  done  in  a  systematically 
clean  way.  The  price  of  salmon  depends  somewhat  on  the  heaviness  of  the  an- 
nual runs  at  the  various  sources  of  supply  on  the  Northwestern  coast  rivers,  and 
more  on  the  variety  of  the  fish,  the  so-called  sockeye  salmon,  a  small  but  very  deli- 
cate variety,  being  easily  first  in  desirability  as  it  is  highest  in  price.  The  Fraser 
and  Columbia  river  varieties  seem  to  have  the  next  call,  though  they  are  identical 
with  the  Alaska  and  neighboring  kinds;  the  cheapest  is  the  dog  salmon,  a  coarse- 
grained fish,  usually  covered  with  sores  when  caught  as  the  result  of  fighting  over 
the  rocks  and  falls  toward  the  spawning  grounds.  It  is  too  bad  the  world  markets 
are  not  better  supplied  with  dried  salmon,  which  makes  a  most  delicious  dish  when 
creamed  or  stewed  or  made  into  cakes  or  balls,  far  superior  in  flavor  to  cod. 

PURCHASE  OF  EGGS 

Eggs  are  divided  into  a  number  of  classifications,  some  of  them  commercial 
and  some  of  them  domestic.  Of  course,  in  the  produce  markets  we  have  the  various 
grades  of  eggs,  such  as  strictly  fresh,  fresh  firsts,  seconds,  dirties,  and  just  eggs. 
These,  however,  are  arbitrary  classifications  that  are  not  sufficient  for  the  pur- 
poses of  the  buyer,  and  these  classifications  may  mean  something  or  nothing,  and 
generally  fall  very  far  short  of  telling  the  whole  story  about  eggs. 

Such  a  classification  as  this  is  better: 

Fresh  eggs,  stale  eggs,  cold-storage  eggs,  incubator  eggs,  and  unusable  eggs. 

It  is  not  often  that  we  can  buy  strictly  fresh  eggs,  and  when  we  do  we  must 
usually  pay  more  for  them  than  most  institutions  can  afford;  the  exception  to  this 
rule  is  in  the  springtime,  as  for  instance  about  May  and  June,  when  most  of  the 
hens  in  the  country  are  laying,  and  when  eggs  are  being  bought  up  for  the  cold- 
storage  people  to  save  over  for  high  prices  next  winter.  Stale  eggs  are  those  that 
have  not  gone  into  the  cold-storage  warehouses,  but  have  ceased  to  be  strictly  fresh. 
Generally  speaking,  these  eggs  have  been  washed,  and  the  air  has  been  allowed  to 
permeate  through  the  shell  and  to  chemically  decompose  the  yolk  to  such  an  extent 
that  oxids  and  sulphids  are  allowed  to  form ;  the  taste  of  stale  eggs  is  due  to  sul- 
phureted  hydrogen.  When  eggs  are  first  laid  they  are  covered  with  a  mucilaginous 
coat  which  perfectly  excludes  the  air;  this  coating  is  an  albuminous  substance,  easily 
soluble  in  water,  and  when  the  eggs  are  washed  the  coating  is  destroyed,  and  thus 
the  air  is  enabled  to  penetrate.  On  inspection  these  eggs  have  a  dead  look  about 
them,  without  any  gloss  whatever,  and  they  are  very  deceptive,  and  do  not  admit 
of  classification  by  means  of  the  transillumination  of  candles.  They  appear  under 
the  candle  process  perfectly  clear,  and  would  be  taken  for  strictly  fresh  eggs  by  the 
most  acute  inspector  but  for  the  air  space  which  we  shall  see  about  later. 

Incubator  eggs  are  coming  into  evidence  more  every  year.     They  are  simply 


1*1   HUI  \SK    i  IK    SI   I'I'I.IKS  555 

an  exaggerated  or  an  aggravated  stale  egg.  They  make  their  appearance  early  in 
the  spring,  and  are  nearly  always  palmed  off  as  strictly  fresh  eggs.  These  eggs 
have  started  on  their  career  by  being  put  into  incubators  for  hatching  purposes. 
The  first  eggs  of  the  early  spring,  or  last  eggs  of  winter,  are  rarely  very  fertile,  often- 
times not  more  than  40  or  50  per  cent,  being  impregnated.  They  are  placed  in 
the  incubator  at  103°  F.,  and  are  left  there  from  three  to  five  or  more  days.  The 
beginning  chick  can  be  detected  in  a  clear  white  egg  on  the  third  day  of  its  incuba- 
tion; in  brown  eggs,  on  the  fifth  day.  When  the  incubator  full  of  eggs  is  tested  out, 
those  that  have  not  started  to  germinate  are  put  aside  and  are  sold  as  strictly  fresh 
eggs;  as  a  matter  of  fact,  they  have  aged  about  as  much  as  an  egg  would  under 
ordinary  circumstances  in  two  or  three  months.  There  is  no  method  by  which 
these  incubator  eggs  can  be  detected,  excepting  that  when  held  up  to  the  light  it 
will  be  seen  that  a  considerable  air  space  has  appeared  in  the  large  end  of  the  egg, 
or,  unless  the  incubation  has  been  very  carefully  handled  and  the  eggs  turned 
frequently,  this  air  space  may  appear  on  the  side  of  the  egg.  A  strictly  fresh  egg 
is  one  in  which  the  shell  is  full  of  meat  and  in  which  there  is  no  air  space.  The 
older  the  egg  is  the  greater  the  air  space  will  be,  and  the  incubator  egg  will  have  all 
the  outward  appearances  of  being  strictly  fresh,  but  will  have  considerable  air 
space. 

Dirty  eggs  are  not  always  bad  eggs,  and,  if  they  can  be  bought  directly  from  the 
farm  or  from  the  country  grocer,  they  may  be  fresh.  These  eggs  are  dirtied  in  one 
of  two  or  three  ways — either  the  hens'  nests  are  allowed  to  become  foul,  because  the 
hens  are  allowed  to  roost  upon  them  as  well  as  lay  in  them,  or  they  are  the  eggs  of 
hens  that  have  laid  out  in  the  weather  and  that  have  become  wet,  and  then  are 
allowed  to  dry  in  touch  with  the  wet  nest  material,  which  stains  them.  In  this 
latter  case  the  soiling  will  have  a  sort  of  yellow,  weathered  look.  In  the  former 
there  will  be  particles  of  manure  sticking  to  the  egg.  The  class  of  these  eggs  can 
be  easily  judged  by  candling,  and  they  are  about  the  only  eggs  that  can  be  detected 
by  candling,  except  the  strictly  fresh. 

The  candling  process  of  eggs  is  not  only  for  the  purpose  of  determining  whether 
there  is  a  chick  inside,  but  to  determine  as  well  the  age  of  the  egg,  measured  by  the 
amount  of  air  space  in  the  shell.  It  can  be  set  down  as  a  definite,  unalterable  fact 
that  an  egg  that  has  a  perfectly  clear  inside,  without  any  spot,  and  that  has  no  air 
space,  is  a  strictly  fresh  egg,  and  that  is  the  only  egg  that  can  be  called  so. 

It  goes  without  saying  that  we  can  very  much  better  afford  to  pay  more  for 
eggs  that  are  all  good  than  we  can  for  eggs  that  have  a  certain  percentage  that  are 
bad  or  old.  In  some  markets  eggs  are  classified  by  percentages,  all  those  about 
80  per  cent,  being  considered  practically  strictly  fresh.  If  we  ask  the  egg  tester 
what  80  per  cent,  means,  he  will  say  that  it  means  that  80  per  cent,  of  the  eggs 
are  good  and  20  per  cent,  of  them  are  not  good;  that  is  not  what  the  classification 
means  at  all,  or  at  least  it  is  not  what  the  classification  was  intended  to  mean  when 
it  was  established.  The  80  per  cent,  means  that  there  is  20  per  cent,  or  less  of 
deterioration  in  all  the  eggs. 

It  is  a  subject  of  almost  mathematic  calculation  whether  eggs  can  be  fed  to  an 
institution  economically  or  not.  Most  institutions  have  a  definite,  established 
meal  for  the  working  forces,  the  breakfast,  because  of  its  simplicity,  being 
perhaps  more  amenable  to  exact  calculation  as  to  price  rather  than  dinner  or  sup- 
per. If  it  takes  fifty  loaves  of  bread  and  25  pounds  of  cereal,  ami  one  hundred 
oranges,  and  7  pounds  of  coffee  to  make  a  breakfast  for  a  given  number  of 
people,  we  can  figure  precisely  what  that  breakfast  i>  costing.  Then,  if  we  want  to 
substitute  bacon  and  eggs,  we  can  determine  just  exactly  how  much  money  we  can 


556  OPERATION    OF   THE    HOSPITAL 

afford  for  the  bacon  and  eggs.  If  eggs,  at  20  cents  a  dozen,  will  foot  up,  including 
the  other  articles  of  the  meal,  just  what  the  breakfast  would  foot  up  with  fruit 
substituted,  we  have  a  gauge  by  which  to  measure  whether  we  can  afford  to  feed 
eggs.  It  may  be  safely  doubted  whether  it  will  ever  be  economic  to  feed  boiled 
eggs  to  working  help  in  an  institution;  eggs,  while  extremely  nutritive,  do  not  go 
very  far  toward  forming  bulk,  or,  as  the  stock  raisers  would  say,  "roughness," 
but  bacon  is  not  only  a  most  nutritive  food,  but  is  a  "filling"  food,  and  holds  one 
up  a  long  time;  so  that  eggs  with  bacon  make  a  well  rounded-out  meal,  and  then 
if  bread  or  toast  or  coffee  cake  and  coffee  are  added,  the  people  will  nearly  always 
be  well  satisfied.  Poached  eggs  on  toast  are  much  more  satisfying  than  boiled  eggs, 
because  of  the  bulk  of  the  toast. 

Roughly  speaking,  the  best  housekeepers  are  disposed  to  feel  that  eggs  at  20 
cents  a  dozen  are  cheap  enough  to  feed  to  the  common  help  at  least  two  or  three 
times  a  week.  Eggs  at  25  cents  may  be  fed  to  the  higher  order  of  institution  em- 
ployees, such  as  the  nurses  and  interns.  When  eggs  get  above  that  figure  they 
should  be  kept  for  the  patients. 

The  problem  of  buying  eggs  in  large  or  small  lots  is  not  a  very  serious  one  in 
most  parts  of  the  country  now.  Nearly  all  institutions  must  buy  their  eggs  from 
middlemen  at  best,  and  they  can  be  had  so  frequently  that  it  will  hardly  pay  to 
lay  in  a  large  quantity.  If  one  cares  to  watch  the  market  closely  enough,  and  has 
cold-storage  room  for  a  considerable  quantity,  quite  a  little  saving  can  be  made  by 
gambling  a  little  in  the  commodity;  that  is,  by  buying  for  a  week  ahead,  if  the 
eggs  should  happen  to  be  "off"  in  price  occasionally.  The  facilities  of  the  cold- 
storage  warehouses,  however,  pretty  evenly  take  care  of  this  angle  of  the  business, 
and  it  is  too  often  a  fact  that  the  cold-storage  warehouse  people  are  so  much  better 
gamblers  than  the  institution  buyers  can  possibly  be  that  the  latter  will  usually 
get  the  worst  of  any  attempt  to  anticipate  the  market,  so  that  in  the  course  of  a 
year's  buying  there  will  hardly  be  much  saving  from  any  attempt  to  keep  posted  on 
the  ranges  of  the  market  in  a  commodity  that  lends  itself  so  well  to  the  machina- 
tions of  the  cold-storage  experts. 

THE  PURCHASE  OF  BUTTER 

Some  of  the  ablest  bacteriologists  in  the  country  have  been  devoting  their 
time  almost  exclusively  for  some  years  to  microscopic  and  chemic  study  of  butter. 
They  have  not  realized  very  much  of  value  to  those  of  us  who  must  buy  butter  for 
daily  consumption  in  an  institution.  It  is  not  even  certain  as  yet  that  pathogenic 
forms  of  bacteria,  such  as  the  colon,  are  harmful  in  butter,  because  a  good  many 
of  the  bacteriologists  are  of  the  opinion  that,  in  the  process  of  ripening  by  the 
activities  of  the  so-called  lactic  acid  bacteria,  the  colon  and  other  pathogenic 
forms  of  micro-organisms  are  practically  destroyed;  in  other  words,  that  there  is  a 
period  of  acidity,  or  a  degree  of  acidity,  to  which  cream  arrives  in  ripening  which 
has  the  effect  of  destroying  the  pathogenic  micro-organisms. 

We  may  take  up  numerous  publications  from  experiment  stations  in  various 
states,  or  from  the  Agricultural  Department  of  the  Government,  and  we  shall  find 
there  perfect  mazes  of  figures,  showing  numbers  and  character  of  bacteria  in  butter 
at  various  ages  after  it  has  been  made,  and  under  varying  conditions  as  to  tempera- 
ture, cleanliness,  and  character,  but  at  the  end  of  all  these  figures  we  are  brought 
to  a  sudden  realization  of  the  fact  that  we  can  distinguish  pretty  nearly  as  much 
by  the  taste,  aroma,  rancidity,  or  freshness  of  the  article  as  the  scientist  can  by  an 
intricate  process  of  microscopic  bookkeeping  on  the  article;  so  that,  for  our  purposes, 


PURCHASE   OF   SUPPLIES  557 

the  proper  purchase  and  character  of  butter — we  shall  be  pretty  safe  in  discarding, 
at  least  until  the  scientists  have  gone  farther  and  fared  better  with  their  work,  all 
other  facts,  excepting  that  there  are  three  classes  of  butter  which  we  shall  meet 
with  in  our  day's  marketing — the  first  is  the  best  quality  of  butter,  made  manifestly 
from  clean,  carefully  ripened  cream,  churned  under  well-established  principles  of 
dairying,  and  which  we  can  readily  determine  is  good  butter  by  the  taste  and  smell. 
The  second  is  a  so-called  "renovated  butter,"  and  which  is  made  by  taking  miscel- 
laneous allotments  of  farm-produced  butter  that  has  grown  rancid,  mixing  it  all 
together,  washing  it  to  take  out  the  acids  of  rancidity,  and  drying  it  as  carefully 
as  can  be  done.  The  third  is  butterine,  about  which  we  have  come  to  know  a  great 
deal  by  reason  of  the  government's  activities  in  the  punishment  of  those  who  arti- 
ficially color  it.  Butterine,  as  made  by  the  large  producers,  consists  of  cotton-seed 
<>r  palm  oil  and  the  leaf  and  kidney  tallow  of  beef  or  mutton,  with  a  certain  propor- 
tion of  neutral  lard,  the  whole  being  churned  with  skimmed  milk  or  buttermilk. 
If  the  milk  is  clean  the  product  will  be  good  and  far  wholesomer  than  bad  butter. 

For  our  purposes  all  these  forms  of  butter  have  pretty  well-defined  characteris- 
tics which  can  be  stated  very  clearly.  The  perfect  butter  is  practically  butter-fat 
and  a  certain  residue  of  the  constituents  of  milk,  the  amount  of  this  latter  depending 
on  the  character  and  thoroughness  with  which  the  butter  has  been  washed  and  dried. 
Good,  fresh  butter  contains  several  hundred  million  lactic  acid  bacteria  per  cubic 
centimeter,  the  pathogenic  bacteria  having  been  eliminated  either  by  destruction 
at  the  hands  of  the  lactic  acid  bacteria  or  the  acid  which  these  produce.  The  fat, 
of  course,  is  a  butter-fat  which  has  a  low  melting-point,  in  every  case  lower  than  the 
temperature  of  the  human  body.  Renovated  butter  differs  from  the  above  only 
in  that  it  seems  to  contain  a  large  number  of  pathogenic  micro-organisms,  but  hardly 
ever  a  sufficiently  large  number  to  be  objectionable.  The  ordinary  processes  of 
renovation  of  this  butter — that  is,  the  process  of  washing  and  cleaning — are  not 
sufficiently  complete.  Take  out  all  the  acids  of  rancidity  and  the  butter  does  not 
keep  well,  and  the  difference  in  taste  between  this  butter  and  the  best  butter  is  due 
to  the  presence  of  a  residue  of  these  acids  of  rancidity.  The  butter-fat  in  renovated 
butter  is  finite  the  same  as  that  in  the  best  butter. 

Butterine  differs  from  the  cow  butters  in  two  distinct  particulars:  first,  it  is 
churned  with  the  cheapest  milk,  that  is,  milk  that  is  ordinarily  not  clean,  and  from 
which  none  of  the  pathogenic  organisms  have  been  eliminated,  excepting  in  the 
natural  course  of  ripening  in  the  predominance  of  the  lactic  acid  bacteria:  second, 
and  most  important,  the  beef  or  mutton  fat  which  represents  the  butter-fat  of  the 
cow  butters  is  a  stearin  whose  melting-point  is  a  good  deal  higher  than  the  body 
temperature,  that  is,  around  110°  F. 

Physiologically,  any  of  these  butters  is  perfectly  digestible  in  the  stomach  of 
the  healthy  adult,  that  is,  any  person  who  can  eat  fat  meat  can  eat  and  digesl 
any  of  these  butters.  It  goes  without  saying  that  butterine  should  not  be  fed 
cither  to  children  whose  gastrc-intestinal  apparatus  is  not  very  strong  or  to  sick 
people. 

Thi'  chief  reason  why  manufacturers  insist  on  coloring  butterine  is  to  enhance 
the  appearance  of  the  manufactured  article.  We  have  become  accustomed  to  a 
rich,  yellow  color  in  butter,  and  we  do  Hot  willingly  eat  butter  that  is  free  from  color. 

The  fact  of  an  artificial  color  is  not  objectionable  in  butter:  it  is  merely  a  question 
of  the  harmfulness  or  otherwise  of  the  particular  coloring-matter  employed.     It 

has  been  said  that  there  are  certain  manufacturers  who  color  their  product  by  feed- 
ing large  quantities  of  carrots  to  the  cows,  which  has  the  effect  of  giving  a  high  color 
to  the  butter  made  from  the  cream  from  those  cows,  and  then  using  a  certain  pro- 


558  OPERATION    OF   THE    HOSPITAL 

portion  of  this  highly  colored  carrot  butter  in  the  making  of  the  butterine.  It 
has  also  been  said  that  butterine  is  colored  by  the  use  of  a  small  proportion  of  the 
yolk  of  eggs,  the  particles  very  finely  divided  and  churned  into  the  product.  It  is 
certain  that  neither  the  addition  of  carrot  butter  nor  the  yolk  of  eggs  is  harmful  as 
an  article  of  food.  It  seems  that  the  objectionable  feature  of  artificial  coloring, 
from  the  standpoint  of  the  government,  is  the  use  of  coloring-matters  that  are  sup- 
posed to  be  harmful  in  themselves. 

When  the  bacteriologists  have  gone  a  good  deal  farther  with  their  subject  than 
they  seem  to  have  gone  at  the  present  time  they  will  probably  find  that  the  digesti- 
bility of  butter  depends  quite  as  much  on  the  character  of  the  cow  which  has 
furnished  the  butter-fat  as  upon  any  other  items  or  conditions.  We  have  gone  far 
enough  already  to  know  that  the  butter-fat  globule  of  the  Jersey  cow  is  several 
times  larger  than  that  from  the  Holstein-Friesian,  and  that  the  difference  is  suffi- 
cient to  make  or  mar  the  health  of  a  young  calf.  In  other  words,  the  keepers  of 
Jersey  herds  oftentimes  employ  a  Holstein-Friesian,  or  common  cow,  to  raise 
high-bred  Jersey  calves,  because  the  calf's  own  mother's  milk  contains  a  butter- 
fat  globule  too  large  to  go  into  the  circulation  readily;  whereas,  the  smaller  fat 
globule  goes  through  very  readily.  This  is  the  reason  why  mothers'  milk,  the 
butter-fat  globule  of  which  is  infinitesimal  in  size,  is  better  for  the  young  baby 
than  cows'  milk,  and  why  asses'  milk  and  goats'  milk,  which  have  likewise  an  infi- 
nitely small  butter-fat  globule,  come  next  in  the  order  of  preference. 

Butter  keeps  very  well  in  cold  storage;  so  well,  indeed,  that  it  seems  almost 
unnecessary  at  any  season  of  the  year  to  lay  in  any  considerable  quantity.  It  is 
true  that  in  the  winter  time  and  in  the  early  spring,  before  the  grass  is  visible, 
butter  is  usually  much  higher,  but  this  is  due  only  to  the  fact  that  the  average  farmer 
allows  his  cows  to  go  so  low  in  their  milking  when  they  are  stable  fed  that  they  do 
not  make  very  much  butter,  and  consequently  the  cold-storage  houses  have  almost 
a  monopoly  of  the  business. 

THE  PURCHASE  OF  FRESH  FRUITS 

Nearly  all  fresh  fruits  used  in  this  country  are  home-grown.  A  few  Spanish 
grapes  are  imported,  and  are  used  mostly  in  the  eastern  states;  there  are  not 
enough  of  them,  however,  to  supply  the  American  market  at  a  price  that  people 
will  pay.  A  great  many  lemons  are  imported  from  Spain,  Italy,  and  the  Mediter- 
ranean country,  but  they  come  at  a  time  when  California  lemons  are  extremely 
scarce  and  not  very  good;  a  good  many  oranges  are  grown  in  Porto  Rico  and  brought 
to  this  country  by  way  of  New  Orleans  and  the  Florida  ports,  but  the  Porto  Rico 
importations  hardly  figure  in  the  orange  market  because  of  their  comparatively 
small  number.  Cuban  oranges,  so  far  as  the  United  States  is  concerned,  have 
practically  disappeared  from  the  market;  importers  say  that  they  do  not  keep, 
and  even  in  the  short  hauls  from  Cuba  to  New  Orleans,  or  from  Cuba  to  the  Atlantic 
seaboard,  they  speck  badly  and  are  rendered  unfit  for  market.  California  sup- 
plies practically  all  the  tropical  fruits  used,  excepting  pineapples  and  bananas, 
which  come  from  the  far  south.  Fortunately,  the  variations  in  temperature  and 
climate  generally  of  California,  and  the  variations  in  the  methods  of  fruit  pro- 
duction of  that  state  under  irrigation  systems,  permit  very  long  seasons.  Lemons 
and  oranges  are  both  ripened  practically  throughout  the  year,  and  a  tree  may  have 
blossoms  and  ripe  fruit  at  the  same  time.  Id  the  northern  part  of  the  state  oranges 
ripen  later  than  in  the  south;  the  trees  bear  longer  in  the  south,  but  those  raised 
in  the  high  altitudes  of  the  south  and  those  raised  in  the  north  of  California  and 


PURCHASE   OF  SUPPLIES  559 

in  Oregon  and  Washington  are  noted  for  a  better  flavor  than  those  distinctly 
southern,  and  also  for  a  firmer  meat. 

California  fruits  are  growing  higher  in  price  every  year,  and  this  promises  to 
be  still  more  marked  as  the  state's  fruit  industry  becomes  organized  into  something 
that  is  already  very  closely  approaching  a  giant  trust;  indeed,  we  have  to  thank 
California  to-day  for  the  fact  that  the  duty  on  lemons  imported  from  the  Mediter- 
ranean orchards  is  50  cents  higher  than  it  was  before  the  late  tariff  law  went  into 
effect.  Previously  the  duty  was  70  cents  per  box.  It  is  now  $1.18.  This  increase 
in  duty  hardly  helps  California  any  and  does  a  great  injustice  to  the  rest  of  the 
country,  because  we  do  not  use  Mediterranean  lemons  when  there  are  any  to  be 
had  from  California.  As  we  have  said  before,  the  lemon  orchards  of  California  are 
constantly  producing,  but  in  the  late  spring  and  summer  the  production  is  very 
low,  not  enough  for  consumption  even  on  the  Pacific  coast.  Lemons,  of  course, 
are  in  greater  demand  in  the  summer  time,  when  California  has  few  to  sell. 

Neither  lemons  nor  oranges  nor  grapefruit  will  bear  cold  storage.  The  citrous 
fruits  cannot  be  cold  stored  at  all,  because  they  speck  at  once  and  go  to  pieces. 

California  oranges  are  in  the  market  practically  all  the  time,  because  of  the 
length  of  time  that  the  trees  bear  and  the  difference  in  the  time  of  the  commencing 
harvest,  owing  to  the  differences  in  temperature  and  climate. 

Apples  and  pears  can  be  accounted  as  perhaps  the  most  reliable  fruits  that  insti- 
tutions can  count  upon.  Both  of  these  fruits  can  be  kept  in  cold  storage  over  almost 
any  length  of  time.  We  are  coming  to  rely  for  our  apples  and  pears,  and  especially 
for  the  apples,  upon  the  irrigated  lands  of  the  Pacific  coast — Oregon,  Washing- 
ton, and  the  extreme  northern  part  of  California.  Of  course,  in  good  years  we 
get  many  fine  apples  from  the  Atlantic  seaboard,  New  York  State,  and  the  New 
England  States,  Canada,  Michigan,  and  a  few  other  points  of  the  lake  regions,  and 
of  late  years  Arkansas  and  the  Ozark  Hills  of  Missouri  are  coming  into  prominence 
as  apple-growing  sections. 

The  prices  of  all  of  these  fruits  are  fixed,  not  so  much  nowadays  by  the  supply 
as  by  the  artificial  means  of  the  middlemen  who  buy  and  hold  them.  Of  course, 
the  fruitgrowers'  associations  of  California  are  very  nearly  fixing  the  prices  of 
California  fruits,  limited  only  by  the  willingness  of  people  to  buy  the  fruits  and 
by  the  malign  influence  of  railway  dictation.  The  price  of  those  fruits  that  can  be 
cold  stored — apples  and  pears — are  fixed  practically  by  the  cold-storage  warehouses, 
and  the  prices  are  practically  what  people  will  pay,  as  evidenced  by  good  times  and 
the  amount  of  money  the  public  can  afford  to  spend.  All  these  conditions  in  all 
these  fruits  bear  upon  hospitals,  hotels,  sanitariums,  and  other  institutions.  We 
must  take  our  chances  with  the  rest,  and  simply  have  to  pay  the  prices  demanded. 
Sometimes  we  can  help  ourselves  a  little  by  purchasing  in  considerable  quantities 
on  a  low  market,  but  only  to  the  extent  of  a  few  boxes,  ami  nut  enough  to  last  over 
any  considerable  period  of  time. 

Just  a  word  about  the  economic  handling  of  fruit  in  institutions.  Of  course, 
it  makes  very  little  difference  what  size  lemon  we  use,  ami  all  the  difference  in  the 
world  how  much  juice  the  lemon  contains.  There  are  lemons  that  are  practically 
dry  and  that  have  a  line  outward  appearance,  whereas  there  are  poor  looking,  thin- 
skinned,  small  and  rather  dried-up  looking  lemons  that  are  full  of  juice,  I  mi  the 
tact  that  they  are  of  poor  appearance  does  not  make  them  any  cheaper  when  we 
go  to  buy;  while,  on  the  other  hand,  the  lemon  of  fine  appearance  is  regulated  as 
to  price  by  its  appearance  and  not  by  its  real  value. 

Grapes  are,  of  course,  luxuries,  and  are  purchased  as  luxuries,  and  people  buy 
them  quite  as  much  for  their  inviting  appearance  as  they  do  for  their  taste. 


560  OPERATION   OF  THE    HOSPITAL 

There  are  as  many  qualities  of  oranges  as  there  are  sections  in  which  oranges 
are  grown.  Beginning  with  the  large,  magnificent  looking  naval  oranges,  of 
southern  California,  and  ending  with  the  little,  reddish,  thin-skinned  oranges  of 
Cuba  and  Porto  Rico,  we  have  every  variation  in  size,  look,  taste,  and  juiciness. 
The  largest  and  finest  looking  oranges  are  not  the  best  for  eating  purposes,  and  they 
are  not  always  the  best  for  an  institution  to  buy,  even  when  the  price  is  right,  and 
this  brings  us  to  a  question  of  the  serving  of  fruit  economically.  A  box  of  oranges 
is  a  box  of  oranges,  everywhere,  as  to  price  and  irrespective  of  size.  In  the  large 
sizes  the  boxes  contain  fewer  oranges,  of  course,  and  those  who  buy  them  do  so 
much  more  for  their  appearance  than  for  their  real  value.  When  institutions  buy 
oranges  they  do  so  for  the  purpose  of  feeding  them  to  patients,  nurses,  interns,  and 
other  hospital  people.  There  are  oranges  that  run  as  low  as  70  to  the  box,  and  there 
are  boxes  that  run  as  high  as  300.  Good  caterers — that  is,  from  the  standpoint  of 
economy  of  service — are  about  agreed  that  oranges  that  run  about  210  to  the  box 
are  the  proper  size  to  buy  if  it  is  intended  to  give  a  whole  orange  to  each  serving, 
while  at  150  to  the  box  the  oranges  may  be  cut  and  served  one-half  to  a  helping, 
thus  giving  about  300  helpings  to  the  box  in  that  case. 

Large  apples  have  no  value  over  medium-sized  ones  from  any  standpoint. 
The  immense,  beautiful  fruit  of  Oregon  and  Washington  is  not  a  very  well-flavored 
fruit,  and  it  is  popular  largely  for  its  magnificent  appearance;  when  apples  are 
served  they  must  be  served  whole,  one  to  each  person,  and  while  some  institutions, 
hotels,  and  hospitals  with  private  accommodations  often  serve  these  beautiful, 
big  apples  to  their  favored  patrons,  they  do  so  on  appearance  alone,  whereas  if 
a  really  serviceable  and  delicious  apple  is  desired  it  can  be  best  had  in  the  medium 
size,  and  especially  the  fruit  grown  in  temperate  climates  of  the  East  and  North. 

We  are  dependent  for  our  pears  on  the  California  product,  and  these  can  be 
cold  stored  for  as  long  a  period  as  two  years  or  even  longer  without  deterioration. 
Peaches  must  be  used  as  they  ripen,  because  they  do  not  keep.  The  California 
product  is  the  handsomest  in  appearance,  the  highest  in  price,  and  the  poorest  in 
flavor.  New  Jersey  and  Maryland  used  to  be  the  most  reliable  source  of  supply, 
with  Michigan  second.  Of  recent  years  the  South,  especially  Georgia,  Texas,  and 
the  Ozarks  of  southern  Missouri,  have  come  to  the  front  in  peach  production,  and 
now  supply  a  large  part  of  the  market.  Most  of  the  plums  come  from  California, 
Oregon,  and  Washington. 

Peaches  and  plums  have  an  extremely  limited  use  for  institution  purposes,  and 
can  be  served  only  raw  and  whole,  either  as  the  beginning  of  breakfast  or  at  the 
end  of  supper.  Apple  and  pears  can  be  served  in  an  infinite  variety  of  ways  at 
almost  any  meal  and  for  any  part  of  the  meal,  either  raw  or  cooked.  For  the  sick, 
baked  apples  or  pears  are  delicious,  wholesome,  and  nutritious.  They  very  fre- 
quently answer  the  question  "What  can  we  serve  for  dessert?  and  their  popularity 
is  enhanced  by  the  fact  that  they  are  to  be  had  at  all  seasons  of  the  year  and  kept 
in  the  institution  cold  rooms  indefinitely. 

PURCHASE  AND  CARE  OF  ROOT  VEGETABLES 

The  root  vegetables  include  potatoes,  white  and  sweet,  the  roots  of  the  turnip 
family — i.  e.,  beets,  rutabagas,  and  turnips  proper,  and  the  long  roots — parsnips, 
carrots,  and  salsify,  or  the  so-called  "oyster-plant." 

There  is  no  secret  about  keeping  these  root  vegetables;  all  that  is  needed  is  that 
they  shall  be  kept  cold  and  dry.  On  the  farm,  parsnips,  carrots,  and  salsify  are 
oftentimes  left  in  the  ground  over  winter,  and  are  gathered  with  an  axe  by  cutting 


PURCHASE   OF  SUPPLIES  5G1 

frozen  chunks  of  earth,  including  the  vegetables.  They  arc  thawed  out  in  cold 
water  and  are  not  in  any  way  hurt  by  the  freezing.  Sweet  potatoes  may  be  also 
frozen,  and  if  used  immediately  after  thawing  in  cold  water  they  will  have  lost 
none  of  their  value. 

The  trouble  with  these  root  vegetables  for  institution  use  is  that  they  can  never 
be  kepi  in  a  cold, even  temperature,  and  any  of  them  will  be  immediately  destroyed 
if  allowed  to  freeze  and  thaw  alternately.  That  is  the  reason  why  they  keep  SO 
much  better  for  the  farmer  in  deep,  dry,  cool  cellars.  If  the  institution  has  such  a 
place  in  which  to  store  its  root  vegetables,  large  quantities  of  them  can  be  laid  in 
very  late  in  the  fall  and  kept  well  until  the  growing  season  in  the  spring,  [f  the 
institution  has  not  such  a  place  to  keep  them  it  will  be  vastly  better  to  buy  a  suffi- 
cient quantity  of  each  or  any  of  them  to  last  a  week  or  ten  days.  It  will  be  useless 
to  attempt  to  keep  them  longer  than  this  if  they  are  bought  in  the  winter  time,  be- 
cause they  will  have  come  from  the  cold-storage  warehouses,  and  we  shall  enlarge 
somewhat  in  another  place  on  the  reasons  why  foodstuffs  cannot  be  taken  from 
cokl  storage  with  the  expectation  that  they  will  keep  any  considerable  length  of 
time  in  any  other  environment. 

Properly  cared  for,  almost  any  of  the  root  vegetables  keep  very  nicely  piled 
up  either  in  a  dry,  cool  cellar,  or,  on  the  farm,  in  pits  dug  in  the  ground  and  covered 
in  layers  of  straw  beneath  heaped-up  earth. 

If  sweet  potatoes  or  yams  are  to  be  kept  they  must  be  gathered  very  carefully 
without  bruising,  and  they  should  be  stored  so  that  the  individuals  will  not  touch 
each  other.  If  they  are  wrapped  in  paper — which  is  not  nearly  so  difficult  a  task 
as  it  seems — they  will  keep  better  than  in  any  other  way,  especially  if  they  are  laid 
up  on  a  shelf,  and  if  they  are  wrapped  the  potatoes  can  be  laid  close  together. 

The  purchase  of  these  root  vegetables  is  not  a  matter  that  requires  very  much 
technical  knowledge,  excepting  in  the  case  of  white  or  Irish  potatoes.  Potatoes 
form  a  very  large  item  of  hospital  food.  In  fact,  it  has  been  pretty  carefully  calcu- 
lated thai  the  average  institution  will  consume  about  one  bushel  of  potatoes  per 
day  per  100  individuals,  and  the  price  of  potatoes  varies  all  the  way  from  50  cents 
per  bushel,  in  the  fall  or  late  summer,  to  $2  per  bushel  in  the  springtime  before 
the  new  crop  conies  in. 

Cold  storage  has  very  materially  lessened  the  difference  between  these  two  prices, 
and  it  is  rare  that  spring  potatoes  cost  more  than  85  cents  a  bushel,  and  almost 
every  year  the  institution  manager  is  confronted  late  in  the  fall  by  the  question 
whether  he  shall  lay  in  a  sufficient  supply  of  potatoes  to  last  over  winter,  or  whether 
be  shall  buy  from  day  to  day,  or  week  to  week,  trusting  that  the  price  will  not  vary 
very  much.  There  is  a  fairly  good  basis  from  which  deductions  may  be  made  as  to 
the  probable  price  of  potatoes  in  the  spring  as  against  thai  of  the  fall.  If  the  potato 
crop  of  the  summer  has  been  good,  or  even  of  average  size,  we  have  been  paying 
about  50  or  55  cents  per  bushel,  in  large  quantities,  at  the  time  when  they  may  be 
bought  for  storage.  The  storage  warehouses  charge  an  average  of  about  1}  cents 
per  bushel  per  month  for  storage.  If  we  purchase  our  supply  in  October  and  use 
out  of  the  supply  until  May,  thai  is,  six  months,  we  must  figure  that  we  shall  have 
to  pay  storage  for  an  average  of  three  months,  or  in  the  neighborhood  of  about  5 
cents,  making  the  potatoes  cost  us  60  cents  if  we  have  paid  55  cents  originally. 
The  loss  by  rotting  is  quite  a  large  item,  and  may  be  figured  conservatively  at  20 

per  Cent.,  taking  the  whole  supply  together.  This  will  add  another  10  or  12  cents 
per  bushel  to  the  price,  making  it  70  or  72  cents.  There  are  very  few  institu- 
tions that  are  so  close  to  a  storage  warehouse  that  they  can  be  delivered  without 
cartage  charges,  and  as  we  cannot   keep  potatoes  fresh  from  cold  storage  longer 


562  OPERATION    OF   THE    HOSPITAL 

than  a  week  or  ten  days  at  most,  this  means  that  we  will  have  to  pay  cartage  charges 
for  potatoes  in  quite  small  quantities,  and  this  will  make  another  considerable  addi- 
tion in  the  cost,  the  amount  of  which  can  hardly  be  figured,  because  it  hangs  upon 
the  distance  from  the  warehouse  and  the  price  of  hauling;  so  it  may  be  readily 
seen  that  our  potatoes  will  have  cost  us  a  good  deal  more  by  the  time  we  use  them 
than  that  represented  in  the  original  expenditure.  If  we  attempt  to  keep  them  in 
the  institution  storage  rooms,  unless  these  are  exceptionally  deep  cellars  and  excep- 
tionally dry,  the  loss  by  rotting  will  be  so  great  as  to  be  practically  prohibitive. 

Taking  the  foregoing  suggestions  into  account,  the  institution  administrator 
will  be  able  to  judge  whether  or  not  it  will  be  best  to  take  the  chance  of  an  increase 
in  the  price  of  potatoes  in  the  open  market,  and  buy  as  he  needs  them,  or  whether 
he  shall  lay  in  a  supply  sufficient  to  answer  for  the  winter. 

However,  if  it  is  determined  to  buy  a  large  quantity  of  potatoes  to  last  until 
the  new  crop  comes  in,  there  are  some  technical  points  about  the  purchase  of  pota- 
toes, quite  well  understood  by  the  farmer  and  by  the  commission  merchant  and  the 
purchasers  for  cold-storage  warehouses,  that  may  not  come  amiss.  In  the  first 
place,  root  vegetables  should  never  be  taken  out  of  the  ground  before  they  are 
thoroughly  ripened  with  the  expectation  of  keeping  them  for  any  length  of  time; 
just  as  an  apple  picked  green  will  be  the  first  to  rot,  so  a  potato,  turnip,  or  carrot, 
gathered  before  it  is  thoroughly  developed  and  ripened,  will  begin  almost  immedi- 
ately to  soften  and  then  to  decay.  There  is  a  way  to  tell  when  the  potato  is  ripe; 
there  is  a  way  to  tell  pretty  definitely  whether  the  potato  has  been  dug  green  or 
allowed  to  ripen  in  the  ground.  Just  under  the  peel  of  the  potato  there  is  ordinarily 
a  cortex  of  very  definite  thickness  and  a  very  clear  outline  that  represents  whatever 
protein  there  is  in  the  vegetable,  the  balance  of  the  potato  being  almost  pure  starch. 
If  the  potato  has  been  picked  before  it  was  ripe  this  protein  layer  will  not  have 
formed  definitely,  and  there  will  be  almost  no  line  of  demarkation  between  it  and 
the  starchy  portion  of  the  vegetable,  and,  if  there  is  not  a  clear  outline  and  a  very 
decided  demarkation,  it  is  certain  that  the  vegetable  will  not  keep  and  was  gathered 
green. 

The  next  point  about  potatoes,  on  which  will  depend  their  keeping  qualities,  is 
that  of  the  soil  in  which  they  were  raised,  and  this  point  must  of  necessity  be  a 
matter  of  honor  with  the  seller.  Those  of  us  who  pay  a  great  deal  of  attention  to  the 
careful  buying  of  food  supplies  are  accustomed  to  buy  northern  potatoes  or  those 
raised  in  the  far  West,  preferably  in  Colorado.  Potatoes  raised  in  Iowa  or  Wiscon- 
sin or  those  raised  in  the  New  England  States  will  keep  very  much  better,  every- 
thing else  being  considered,  than  any  other  potatoes,  excepting  those  raised  in  the 
sandy,  irrigated  desert  lands  of  Colorado,  Montana,  western  Kansas,  and  the  north- 
ern parts  of  Nebraska.  Sandy-soil  potatoes  keep  better  than  those  raised  in  bot- 
tom-lands. 

After  all  is  said  about  the  buying  of  these  vegetables,  however,  it  must  be  frankly 
admitted  that  the  food  commission  business,  acting  jointly  with  the  cold-storage 
warehouse  industry,  has  been  able  to  dominate  the  situation  in  almost  every  com- 
modity, until  it  is  almost  as  much  of  a  gamble,  whether  we  buy  in  large  or  small 
quantities,  as  it  is  when  we  go  into  the  pit  and  buy  future  wheat. 

PURCHASE  OF  CANNED  VEGETABLES 

There  is  almost  as  much  difference  in  canned  vegetables  as  there  is  in  human 
nature,  and  this  is  caused  to  a  great  extent  by  the  fact  that  some  vegetables,  the 
finest  kind,  are  canned  almost  in  the  field  where  they  grow,  and  are  put  up  fresh  and 


PURCHASE    OF   SUPPLIES  563 

firm;  the  vegetable  which  has  to  be  carted  miles  to  a  factory  and  jolted  and  bruised 
will  not  compare  in  flavor  with  goods  handleci  fresh.  Most  packers  of  vegetables 
put  up  two  or  more  grades. 

Brands  of  canned  goods  are  often  misleading;  one  packer's  standards  may  not 
measure  up  to  another's;  this  is  because  there  is  no  authorized  grading.  For  some 
years  the  government  has  been  trying  to  find  some  scheme  of  uniform  classification, 
si i  that  a  standard  brand  would  mean  the  same  wherever  found  and  by  whomever 
packed;  but  the  attempt  has  not  been  successful  up  to  the  present  time.  Even 
a  standard  of  one  packer  this  year  may  not  be  the  same  next  year,  owing  mostly 
to  the  difference  in  the  character  and  cost  of  the  raw  fruit  or  vegetable  in  different 
years;  therefore,  the  only  way  to  buy  either  fruit  or  vegetables  is  to  see  the  samples, 
side  by  side,  with  the  cost  sheets  at  hand.  Then  it  does  not  require  an  expert  to 
buy — the  eye  and  taste  of  a  hospital  steward  and  a  glance  at  the  comparative 
figures  are  enough. 

Preparation  is  a  very  important  part  in  the  art  of  canning,  as,  for  instance,  in 
an  article  like  string  beans,  where  a  packer  is  careless,  and  does  not  sort  his  beans 
as  to  size,  and  does  not  take  care  to  see  that  the  strings  are  removed,  he  will  produce 
goods  known  as  "seconds."  If  the  grit  is  not  removed  from  spinach  as  well  as  the 
hard  stems,  and  if  there  are  nubbin  ends  in  the  corn  and  an  occasional  dark-colored 
grain,  and  if  some  of  the  core  is  left  in  the  tomato,  the  vegetable  may  be  ever  so  good 
on  the  whole,  but  cannot  be  sold  as  first  class. 

Corn  and  tomatoes  are,  of  course,  the  staple  canned  vegetables ;  both  are  bought 
most  economically  in  gallons,  though  it  is  always  well  to  have  a  few  cases  of  small 
cans  on  hand  to  open  for  an  emergency.  The  chief  virtue  in  tomatoes  is  that  they 
shall  be  uniformly  ripe,  and  that  there  shall  be  plenty  of  sound,  solid  meat  and  not 
much  juice;  water  can  be  purchased  at  less  than  tomato  prices. 

There  is  as  much  difference  in  canned  corn  as  there  is  in  corn  served  on  the 
cob;  field  corn  can  never  be  as  delicately  flavored  and  as  fine  grained  as  the  so- 
called  sweet  corns,  whether  in  the  can  or  on  the  cob.  Attempts  are  often  made 
by  packers  to  disguise  this  difference,  either  by  splitting  the  grains  of  coarse  corn 
or  by  cooking  it  until  it  is  soft.  In  the  one  case  the  small  pieces  of  a  large,  coarse 
grain  can  be  readily  seen  with  the  eye,  and  in  the  other  the  whole  can  will  be  a 
mushy  mess,  and  even  a  blind  man  can  distinguish  between  the  two  by  the  taste. 
Field  corn  will  do  very  well  for  the  help  and  is  greatly  relished,  and  it  will  do  nicely 
for  cream  soups,  when  properly  strained,  and  makes  a  most  appetizing  dish  when 
made  into  a  pudding,  with  eggs  and  a  little  sugar.  The  very  finest  grades  of  sweet 
corn  are  not  to  be  found  in  gallon  cans. 

Canned  string  beans  are  not  very  satisfactory  if  wanted  for  a  staple  to  feed  to 
the  well  people;  the  fine  grades  of  small,  tender  stringless  beans  cost  too  much  for 
common  use,  and  the  larger  coarser  kinds  are  not  pleasant  eating,  because  it  is 
extremely  difficult  to  get  the  strings  out  on  a  commercial  scale. 

Peas  are  almost  as  staple  as  corn  and  tomatoes;  they  may  be  had  in  gallons 
or  2'-pound  cans,  any  brand,  quality,  and  size,  excepting  the  so-called  French 
peas,  which  come  only  in  the  small  tins.  Although  peas  are  not  a  very  regular 
or  reliable  crop,  they  keep  well,  and  can  be  laid  in  to  last  more  than  one  year  if 
desired.  Peas  are  usually  graded  according  to  size;  the  smallest  are  the  youngest 
and  most  delicate  and  cost  the  most.  French  peas  are  merely  half-grown  ones, 
picked  and  packed  with  those  peculiarly  French  artistic  touches  that  make  for 
attractiveness  in  appearance  and  delicacy  of  flavor,  both  being  expressed  in 
something  like  double  price.  The  American  packed  French  peas  were  colored 
with   copper    preparations    until    the   pure    food   law;    they   are   now    very   pure, 


564  OPERATION    OF    THE    HOSPITAL 

very  wholesome,  and  very  desirable  as  a  change  from  potatoes,  corn,  and 
tomatoes. 

Spinach  is  another  vegetable  that  is  a  very  welcome  addition  to  the  menu. 
Packers  seem  to  have  some  secret  for  washing  it  free  of  grit,  and  the  canned  variety 
cannot  be  distinguished  from  fresh,  excepting  it  is  smoother  and  cleaner;  moreover, 
spinach  is  a  vegetable  that  requires  much  work  in  preparation,  stemming  and  wash- 
ing, and  it  may  very  fairly  be  doubted  whether,  even  in  the  early  spring,  when  all 
nature  craves  green  things,  it  pays  to  buy  fresh  spinach.     It  comes  best  in  gallons. 

Young  beets  put  up  nicely  and  make  an  attractive  vegetable.  They  must 
be  very  small  and  tender,  and  are  served  best  with  a  butter  sauce.  They  are 
not  cheap,  and  cannot  be  fed  to  the  well  people  of  the  institution  on  that  account. 
Packers  seem  to  retain  the  custom  of  coloring  them  with  cochineal,  which  gives 
them  an  exaggerated  bright  red  appearance.  There  is  not  much  to  them,  but 
they  sometimes  stimulate  a  lazy  appetite,  especially  if  served  cold  as  a  salad. 

Asparagus  is  a  vegetable  about  which  there  are  many  opinions.  The  fresh 
article  in  the  spring  is  a  universal  favorite,  and  there  are  very  few  people  who  are 
not  fond  of  it.  It  is  canned  in  two  general  forms,  the  green  made  of  the  stalk 
that  has  been  above  the  ground  for  two  or  three  days,  and  the  white,  which  is  cut 
below  the  surface  before  it  breaks  through  the  crust  of  the  soil,  and  there  are  two 
general  forms  of  each  of  these  again;  green  tips  are  the  tenderest  tidbits,  cut  an 
inch  or  two  long,  and  cost  more  than  any  other  domestic  form;  then  there  is  the 
long  green  stalk,  including  the  tips,  in  which  there  is  some  waste  in  eating,  because 
only  the  upper  third  is  tender  enough  to  eat. 

The  white  varieties  are  branded  according  to  the  four  forms  of  packing — first, 
the  short,  heavy  white  stalks,  including  tips,  that  are  packed  either  peeled  or  un- 
peeled;  second,  the  long  slender  kind,  also  packed  either  peeled  or  unpeeled.  Not 
nearly  so  much  care  is  taken  in  this  country  about  the  details  of  packing  as  in 
Europe.  The  factories  in  Europe  are  at  the  fields,  and  the  goods  are  peeled,  boiled, 
and  sealed  immediately  after  being  cut.  It  is  certain  that  neither  the  California 
nor  eastern  American  packed  goods  are  as  delicate  of  flavor  as  the  best  grades  of 
European  goods.  The  size  and  length  of  stalk  of  asparagus  is  a  matter  of  a  good 
deal  of  importance  in  serving.  It  makes  no  difference  how  large  around  an  aspara- 
gus stalk  is,  people  will  not  be  satisfied  with  a  service  of  three  pieces.  Cans  of  the 
short  Mammoth  White  contain  only  about  fifteen  stalks,  and  will  serve  only  three 
or,  at  most,  four  people,  while  cans  of  the  long  slender  kind  contain  twenty-five  to 
twenty-six  pieces,  and  will  easily  serve  five  and  often  six  persons ;  this  fact  must  be 
considered  in  buying.  The  test  of  success  in  the  packing  of  a  fruit  or  vegetable  is 
the  nearness  in  flavor  and  appearance  to  that  of  the  fresh  article;  nowhere  is  this 
more  true  than  with  asparagus.  It  is  easy  to  preserve  the  firm  form  and  fresh 
color,  but  the  taste  is  another  thing,  and  a  standard  of  this  year  cannot  be  taken  as 
a  standard  of  next.     The  only  way  to  buy  asparagus  is  to  see  and  taste  the  samples. 

There  is  a  very  cheap  form  of  asparagus,  put  up  either  in  small  tins  or  gallons, 
for  making  soups.  It  is  composed  of  tough  stalks  left  over  after  the  tips  are  cut  for 
a  better  grade  and  cut  into  inch  pieces.  The  taste  for  soups  is  excellent,  and  the 
price  brings  this  grade  within  reach  of  any  institution. 

There  are  other  vegetables  put  up  in  cans,  such  as  okra,  Brussel  sprouts,  cauli- 
flower heads,  and  so  on,  but  these  are  considered  luxuries,  and  are  not  necessary  to 
the  conduct  of  an  institution  kitchen  unless  there  is  a  very  high-class,  exacting 
private  clientele,  when  it  may  be  desirable  to  keep  a  small  quantity  on  hand  in  the 
smallest  cans  to  be  obtained. 


PURCHASE    OF    SITPLIES  565 

PURCHASE  OF  CANNED  FRUITS 
In  determining  the  value  of  canned  goods,  there  are  two  very  essential  requi- 
sites. The  first  thing  to  determine  is  what  grade  of  goods  is  wanted  for  the  pur- 
pose. If  the  finest  grade  is  desired,  the  two  elements  to  be  considered  are  the 
quality  of  the  fruit  itself,  as  to  soundness  and  uniformity  in  size,  and  the  char- 
acter of  the  syrup  in  which  it  is  preserved;  the  syrup  is  usually  made  from 
the  juice  of  the  fruits  and  pure  granulated  sugar.  The  next  point  to  consider 
is  the  size  of  the  fruit  for  serving  purposes,  as,  for  instance,  a  2i-pound  can  of 
peaches,  which  counts  from  ten  to  twelve  pieces  in  the  can,  will  make  six  nice 
portions.  The  same  fruit  exactly,  but  of  a  larger  size,  may  appeal  more  to  the 
eye,  but  from  an  economic  standpoint  will  not  serve  as  many  people,  although 
the  price  is  the  same.  A  can  of  twelve  pieces  will  make  six  full  portions,  while  a 
can  of  larger  fruit,  and  containing  only  seven  or  eight  pieces,  will  only  serve  three 
and  one-half  portions,  and  it  is  human  nature  for  one  to  judge,  at  least  in  a  measure, 
by  the  quantity  he  receives,  and  two  pieces  certainly  seem  more  to  the  average 
person  than  one  piece. 

In  judging  the  quality  of  California  fruits,  and  much  of  our  fruit  comes  from 
there,  it  is  necessary  to  consider  the  section  from  which  they  come;  it  is  a  well- 
known  fact  that  goods  from  the  northern  part  of  the  state  are  much  more  desirable 
and  of  a  better  flavor  than  those  from  the  south. 

The  keeping  quality  of  canned  fruits  is  also  essential;  the  fruits  which  are  pre- 
served without  the  pits,  such  as  peaches,  pears,  and  apricots,  will  keep  almost 
indefinitely,  and  the  length  of  time  they  are  in  the  can  matters  little.  Fruits  which 
are  canned  with  the  pits,  such  as  plums,  cherries,  and  grapes,  do  not  keep  well, 
as  there  seems  to  be  a  germ  in  the  pit  which  is  not  killed  in  processing,  and  which, 
after  a  certain  time,  begins  to  show  life  and  causes  fermentation  to  set  in,  which 
means  swTelled  cans.  It  is  best,  therefore,  not  to  buy  these  fruits  in  very  large 
quantities. 

California  fruits,  as  a  whole,  are  much  prettier  to  look  at  than  those  grown  in 
the  East,  but  the  conditions  under  which  they  are  raised — that  is,  by  irrigation — 
mar  the  flavor.  Eastern  fruits  are  not  nearly  as  luscious  to  look  at,  and,  therefore, 
do  not  always  please  the  buyer  or  user,  but  the  flavor  is  much  finer  and  more  deli- 
cate,  on  account  of  their  being  grown  under  normal,  natural  conditions. 

Peaches,  pears,  and  apricots  are  the  chief  canned  fruits  to  be  depended  on  for 
institution  use  in  dessert  form.  Apples,  especially  the  so-called  "pie-apples," 
are  excellent  for  stewing  and  for  pies,  and  they  can  be  prepared  for  pies  so  that  they 
cannot  be  distinguished  from  fresh  apples,  especially  the  better  brands  which  have 
a  small  amount  of  juice. 

It  pays  to  buy  all  canned  fruits  in  gallon  sizes,  excepting  perhaps  a  small 
amount  of  the  very  best  grades,  a  25-pound  can  of  which  is  convenient  to  open  for 
a  few  patients  or  guests  in  emergency.  The  cost  of  the  gallon  is  lessened  by  the 
fact  that  1 -gallon  cans  cost  much  less  than  four  2J-pound  cans:  the  gallons,  moreover, 
require  less  handling  in  processing,  and  the  labor  bills  will  be  less  for  the  buyer 
to  pay.  Of  course  in  a  small  institution,  where  a  whole  gallon  is  not  to  be  used  ;it 
one  time,  it  is  more  profitable  to  buy  the  2f-pound  cans,  because,  even  with  good 
refrigerators,  there  is  likely  to  be  some  waste  in  the  portions  left  over  even  if  the 
"Jack  Homers"  are  not  about. 

Some  caterers  like  to  have  a  few  small  cans  of  berries  on  the  shelves  to  tempt 
the  appetites  of  patients  who  must  be  given  a  frequent  change.  Some  years  the 
berries  are  cheap  enough,  even  to  serve  to  the  nurses  and  intern-  occasionally, 
and  may  then  be  bought  in  gallons. 


566  OPERATION    OF   THE    HOSPITAL 

The  Purchase  of  Olives. — Up  to  a  few  years  ago  only  the  Spanish  olive  was 
used  in  this  country,  and  there  were  two  sorts — the  queen,  or  large  olive,  and  the 
Manzanilla,  or  small  olive.  The  queen  is  not  nearly  so  abundant  as  the  smaller 
variety,  and  has  always  sold  for  a  larger  price.  In  this  country,  where  the  people 
"eat  so  much  with  their  eyes,"  as  the  French  say,  the  queen  olive  has  always  been 
more  popular,  not  because  of  its  innate  superiority,  but  on  account  of  its  more 
attractive  appearance;  and  Europeans,  with  their  proverbially  frugal  habits,  have 
seemed  perfectly  willing  to  let  their  American  cousins  have  what  they  themselves 
do  not  care  to  pay  for.  In  the  best  cafes  in  Europe  the  Manzanilla  olive  is  served 
as  a  matter  of  course,  and  it  is  the  better  olive  as  to  delicacy  of  flavor,  and  it  contains 
more  actual  oil,  which  is  the  only  food  value  of  the  article. 

Within  the  past  few  years  California  has  made  wonderful  progress  in  the  olive 
industry,  and  the  "product  of  the  golden  west"  has  come  to  be  in  this  country  an 
article  of  actual  food,  because  of  its  nutrient  value,  while  the  Spanish  olive,  either 
the  queen  or  Manzanilla,  is  merely  a  condiment. 

Imported  Canned  Goods  Generally. — The  day  has  gone  by  when  the  epicure  or 
caterer  must  look  to  any  country  but  the  United  States  for  palatable  goods  in  cans, 
because  the  great  moral  wave  that  has  recently  passed  over  this  country,  supported 
by  the  pure  food  laws,  has  compelled  packers  to  put  up  their  goods  without  adul- 
terants or  coloring  matter;  while  most  European  goods,  especially  those  made  in 
France  and  Belgium,  have  sulphate  of  copper  added  as  a  coloring  matter  and  pre- 
servative. There  are  now  only  a  few  specialties,  such  as  Russian  caviar  and  the 
French  long,  slender-peeled  white  asparagus,  that  have  any  actual  value  over  the 
domestic  product.  Even  in  the  sardine  industry  American  packers  are  using  quite 
as  good  oil  as  the  foreigners,  and  consequently  the  sardines  are  quite  as  good,  and 
the  tariff  on  imports  has  made  at  least  a  little  difference  in  price  in  favor  of  the 
American  commodity. 

THE  PURCHASE  OF  COFFEE 

There  are  a  few  staple  articles  for  the  table  that  are  common  to  all  classes  of 
society  in  every  land,  whether  it  be  the  Maharajah  in  his  Oriental  palace,  the 
millionaire  in  his  club,  or  the  pauper  in  his  hovel,  and  coffee  is  one  of  them. 

Without  any  positive  food  value,  and  depending  for  its  place  in  society  on  its 
stimulant,  sedative,  and  more  or  less  sentimental  nature,  coffee  has  one  rival 
only — tea.  It  has  no  place  whatever  in  an  institution  maintained  for  the  care  of 
the  sick;  it  is  never  beneficial  to  the  sick,  and  often  positively  hurtful;  it  cannot 
be  good  for  nurses  and  interns,  because  the  young  do  not  need  artificial  stimulation 
of  their  physiologic  functions;  and  the  common  help  need  nourishing  foods  to  enable 
them  to  do  their  work,  and  not  stimulants  that  presently  produce  a  lethargy  too 
often  present  without  any  external  aid.  And  yet  coffee  has  come  to  be  one  of 
the  prime  necessities  in  institutional  life.  And  we  must  accept  it  and  try  to  use 
it  properly. 

Coffees  have  been  comparatively  cheap  of  recent  years  until  about  five  years 
ago,  and  it  was  said  that  coffee  growers  were  not  making  a  living.  Brazil  had,  in 
the  past  twenty  years,  encouraged  the  growing  of  coffee  to  such  an  extent  that 
in  the  year  1906  that  country  alone  raised  in  one  year  enough  coffee  to  supply 
the  entire  world  for  two  years.  It  was  necessary  at  the  time  of  this  enormous  pro- 
duction for  the  Brazilian  national  government  to  find  means  for  the  protection 
of  its  coffee  planters,  and  to  try  and  maintain  a  fair  market  price  for  their  product, 
and  they  passed  what  was  known  as  the  "Valorization  Law,"  for  the  purpose  of 


PURCHASE    OF    SUPPLIES  567 

raising  money  to  buy  and  take  off  the  market  whatever  coffee  was  not  needed  for 
immediate  consumption. 

To  effectively  accomplish  their  purpose  and  make  it  possible  to  market  the 
surplus  in  future  years,  it  was  necessary  to  find  a  means  of  curtailing  production 
and  reduce  the  succeeding  crops;  and  they  passed  laws,  one  prohibited  the  culti- 
vation of  any  new  acreage  in  coffee,  another  taxed  the  replanting  of  an  old  acreage 
so  heavily  that  it  was  made  prohibitive.  The  effect  of  these  laws  is  now  being  felt — 
production  has  decreased  until  it  is  now  less  than  the  amount  required  for  consump- 
tion. Brazil  has  been  supplying  four-fifths  of  all  the  coffees  consumed,  and,  with 
the  change  in  its  product,  all  other  varieties  of  coffee  have  acted  in  sympathy,  and 
there  has  been  a  general  advance  in  price. 

With  Brazil  in  the  healthy  condition  that  she  is  to-day,  and  with  its  strong 
financial  position,  and  the  backing  which  it  has  from  the  greatest  financial  syndi- 
cate ever  known,  it  is  not  reasonable  to  suppose  that  there  will  be  any  action  to 
cheapen  the  price  of  its  principal  industry- — coffee.  The  trade  is  given  to  under- 
stand publicly  and  privately  that  it  is  the  purpose  to  continue  the  control  of  produc- 
tion and  the  market  price  by  legislation,  the  use  of  money,  and  the  valorization 
scheme,  and,  in  the  opinion  of  the  most  conservative,  higher  prices  have  come  to 
stay,  and  future  selling  prices  will  have  to  be  advanced. 

On  the  island  of  Porto  Rico,  U.  S.  A.,  is  produced  a  very  limited  amount  of 
coffee;  it  is  of  stylish  washed  character,  with  an  attractive  yellowish  center,  has  a 
rich  oily  flavor,  is  moderately  acid,  and  of  good  strength.  The  American  people 
have  not  as  yet  been  educated  to  its  use,  and  nearly  the  entire  production  is  sold 
to  Europe  at  higher  prices  than  the  American  trade  will  pay. 

The  Philippine  Islands  raise  some  coffee,  but  very  little  is  exported.  The 
Hawaiian  Islands  also  have  their  limited  production. 

The  Dutch  East  India  Islands  have  for  many  years  exported  what  is  generally 
conceded  to  be  the  finest  coffee  in  the  world.  They  also  produce  some  less  desir- 
able. Mexico  has  an  important  place  in  coffee  growing,  and  raises  some  of  the 
finest  as  well  as  the  poorest;  the  poorer  grades  are  grown  more  or  less  wild  by  the 
Indians,  while  the  better  ones  have  careful  cultivation. 

South  America  produces  over  90  per  cent,  of  all  the  coffees  consumed.  Vene- 
zuela has  her  Maracaibo,  United  States  of  Columbia  her  Bogotas,  and  nearly  all 
the  other  tropical  countries  are  coffee  producers. 

Brazil  is  the  greatest  coffee-growing  country  in  the  world,  Sao  Paulo  being  her 
principal  growing  state.  The  best-known  varieties  from  Brazil  are  Santos,  Rio, 
Victoria,  Bahia,  and  Minas.  These  varieties  have  their  distinct  characteristics 
and  an  individuality  of  flavor.  About  75  per  cent,  of  the  millions  of  pounds  of 
coffee  consumed  in  the  world  comes  from  the  state  of  Sao  Paulo.  The  growing 
of  coffee  is  the  principal  industry,  and  the  name  is  taken  from  the  city  of  Santos, 
through  which  port  nearly  all  of  the  Santos  coffees  are  exported.  While  Sao  Paulo 
coffees  take  the  name  of  Santos  there  are  a  great  many  different  types,  grades,  and 
qualities.  The  three  principal  classes  are  Santos,  Bourbon  Santos,  and  Santos 
Peaberry.  The  regular  Santos  has  a  smoother  and  more  attractive  bean  than  the 
Bourbon,  which  is  more  or  less  irregular  and  curly;  the  Peaberry  is  the  male  bean 
and  round;  the  soil  in  the  state  of  Sao  Paulo  and  its  climate  are  particularly  well 
adapted  for  coffee  growing.  The  wonderful  cultivation  of  Santos  coffee  has  in  recent 
years  advanced  so  rapidly,  and  the  quality  has  so  improved,  that  it  has  displaced 
other  varieties  of  higher  cost,  and  has  even  been  shipped  into  Sumatra  Island, 
the  home  of  the  finest  so-called  Javas. 

It  has  been  stated  on  authority  that  in  the  past  ten  years  the  average  price  of 


568  OPERATION   OF   THE    HOSPITAL 

coffees  imported  by  the  United  States  has  been  about  10  cents  per  pound  roasted; 
this  statement,  in  a  sense,  has  created  a  wrong  impression;  there  is  a  great  quantity 
of  the  poorer  grades  of  coffee  sold;  one  local  market  requires  one  grade  of  coffee  while 
another  will  take  a  different  grade  and  type.  This  10-cent  average  does  not  rep- 
resent the  price  demanded  for  the  finer  quality,  and  is  only  a  general  average 
estimate,  including  the  undesirable.  The  import  cost  for  the  more  satisfactory 
grades  is  from  14  to  28  cents  for  roasted  coffee. 

Coffee  Substitutes. — For  some  time  the  consumption  of  coffee  has  increased 
steadily  every  year.  Its  popularity  has  encouraged  production  to  the  extent  of 
overproduction.  Enterprises  have  been  promoted  with  success  to  sell  coffee  sub- 
stitutes at  the  expense  of  the  genuine.  The  latest  novelty  is  doctoring  the  coffee 
bean  to  make  it  more  or  less  artificial  by  extracting  the  caffein;  the  active  principle 
of  coffee  is  caffein,  which  is  the  stimulating  ingredient;  this  is  extracted  from  the 
coffee  beans  and  is  sold  at  a  high  price  on  account  of  its  highly  medicinal  properties. 
Nature  has  intended  that  caffein  shall  be  in  coffee,  and  when  it  is  extracted  it 
leaves  a  tasteless  product  without  anything  to  recommend  it. 

In  years  past  coffee  substitutes  were  used  more  or  less  to  cheapen  the  price 
of  genuine  coffee,  and  in  so  doing  there  were  dealers  who  sold  the  mixed  product 
as  pure  coffee  and  deceived  their  customers.  These  abuses  have  been  regulated 
by  the  National  Pure  Food  Law,  and  if  any  products  are  now  mixed  with  the 
genuine  coffee  bean  the  package  must  be  labeled  according  to  the  contents. 

Chicory  has  been  used  more  or  less  to  mix  with  coffee,  and  the  Germans,  in 
particular,  prefer  a  pinch  of  chicory  mixed  with  even  the  very  finest  of  coffee; 
chicory  has  a  syrupy  flavor  which  is  very  agreeable  and  thickens  a  coffee  consid- 
erably. When  it  is  used  the  ruling  of  the  Pure  Food  Commissioner  is  that  the  pack- 
age must  be  marked  with  the  proportion  of  coffee  and  chicory  which  it  contains. 
Peanuts,  chicory,  steam-cooked  peas,  breadstuff's,  and  roasted  cereals  have  been 
in  time  past  the  principal  substitutes  for  coffee — they  have  been  used  in  different 
ways  to  deceive  consumers.  This  condition  has  now  been  eliminated;  there  used 
to  be  a  combination  sold  which  contained  chicory,  peas,  and  coffee,  and  was  known 
to  the  trade  as  "crushed  Java."  It  was  sold  in  a  broken  condition,  and  the  peas 
and  chicory  mixed  looked  very  well  with  the  coffee;  when  this  combination  is  now 
sold  it  must  be  branded  "Coffee  Compound — Coffee,  Chicory,  and  Peas." 

The  question  of  what  price  an  institution  must  pay  for  coffee  to  obtain  a  satis- 
factory article  depends  on  a  good  deal  besides  the  grade  of  the  coffee  itself.  About 
one-half  the  value  of  coffee  is  in  the  making — a  poor  quality  of  coffee  at,  say,  18  or 
20  cents,  but  well  made,  will  be  far  better  than  a  40-cent  coffee  made  badly. 

Purchase  of  Cooking  and  Kitchen  Utensils 

It  is  difficult  to  persuade  the  average  chef  or  cook  to  change  from  the  particular 
kind  of  kitchen  ware  he  or  she  has  been  accustomed  to  use,  and,  in  the  absence  of 
actual  figures  to  prove  the  value  of  one  kind  or  style  or  metal  over  another,  an  obvi- 
ously impossible  thing  to  obtain,  no  dissertation  on  the  subject  will  go  very  far 
toward  changing  the  opinion  of  the  culinary  experts. 

But  there  are  some  well-known  advantages  and  disadvantages  in  favor  of  and 
against  all  kinds  of  kitchen  ware. 

Granite  Ware. — Thirty  years  ago,  when  the  Niedringhaus  Brothers  of  St.  Louis, 
Missouri,  began  to  make  their  famous  "granite  ware"  it  at  once  took  a  prominence 
that  defied  competition,  somewhat  after  the  fashion  of  aluminum  ware  of  a  score  of 
years  later,  and  the  patentees  of  the  process  became  enormously  wealthy.     The 


PURCHASE    OF    SUPPLIES  569 

ware  was  made  on  honor,  so  to  speak,  and  its  lasting  quality  was  so  much  greater 
than  that  of  anything  else  there  was  no  comparison.  But  when  the  patents  expired 
every  maker  of  kitchen  utensils  began  making  "granite  ware"  and  the  competi- 
tion grew  so  keen  that  the  quality  suffered  immensely.  A  piece  of  the  original 
granite  ware  could  be  dropped  on  a  stone  floor  without  chipping,  and  the  glazed 
covering  of  the  steel  material  remained  intact  almost  indefinitely,  so  that  there  was 
no  possibility  of  rust  and  erosion.  But  with  the  quality  made  to-day  it  is  differ- 
ent ;  if  an  article  drops,  there  is  a  dent  and  a  chip  of  glaze,  and  even  the  use  of  the 
stirring  spoon  soon  wears  the  glaze  off  the  inside.  About  the  only  thing  in  favor  of 
the  granite  wear  of  to-day  is  that  it  is  cheaper  than  most  other  kinds  as  to  first 
cost. 

Enamel  Ware. — Enamel  was  the  logical  successor  of  granite,  and,  when  the 
latter  came  into  disrepute,  smart  manufacturers  turned  to  the  former;  that,  too, 
has  now  become  so  completely  the  victim  of  competition  that  its  virtues  are  all 
but  gone.  Its  value  over  granite  lies  in  its  whiteness  and  cleanliness  so  long  as 
it  is  new;  but  it  soon  chips  and  discolors,  especially  on  the  bottom,  and  for  that 
reason  is  not  very  popular.  There  is  an  enamel  ware  made  in  Austria  that  is  far 
better  than  any  made  in  this  country.  It  comes,  not  only  in  kitchen  utensils,  but 
in  almost  every  conceivable  form — toilet  sets,  hospital  vessels,  and  table  dishes. 
It  costs  more  than  the  American  made  goods  and  is  well  worth  the  difference. 

Tinned  Steel. — The  cheapest  of  all  kitchen  utensils,  and  the  most  common,  are 
made  of  steel  covered  with  one  or  more  coats  of  tin.  As  long  as  the  tin  remains 
the  utensils  do  not  corrode  or  rust,  and  articles  can  be  retinned  any  number  of 
times  advantageously  and  rather  cheaply  unless  they  have  to  be  sent  a  long  dis- 
tance to  the  repair  shop.  There  is  no  way  of  telling  how  heavily  the  steel  is  coated, 
and  one  must  trust  the  manufacturer.  Thin-coated  stuff  is  not  worth  buying,  and 
it  is  impossible  to  use  the  ware  after  the  tin  is  worn  off,  because  the  iron  begins  to 
corrode  at  once  and  to  color  anything  cooked  in  it. 

Copper  Ware. — Many  cooks  prefer  copper  utensils,  either  bare  or  tinned. 
Copper  is  not  altogether  free  from  danger;  certain  vegetable  acids,  alkalis,  and 
cleansing  solutions  and  powders  will  act  on  copper,  and,  unless  the  vessels  are  very 
carefully  cleaned  before  using,  soluble  poisonous  chemic  compounds  are  liable,  to 
be  present  in  the  food.  Copper  will  last  longer  than  any  form  of  iron  or  steel 
ware,  and,  if  properly  handled,  there  can  be  no  objection  to  it.  Tomato  juice,  so 
harmful  to  agate,  granite,  enamel,  and  tin,  has  no  effect  on  copper. 

Aluminum  Ware. — Aluminum  cooking  utensils,  while  having  some  disadvan- 
tages, have  proved  themselves  the  most  satisfactory  of  all  cooking  ware  for  institu- 
tion use. 

Their  disadvantages  are  usually  due  to  imperfection  in  manufacture  and  to 
impurities  or  alloys  in  the  metal  used.  Aluminum  being  a  comparatively  new  metal, 
its  characteristics  and  properties  are  not  thoroughly  understood  by  manufacturers, 
consequently  aluminum  utensils  are  not  always  satisfactory.  Its  groat  advantages, 
however,  outweigh  any  disadvantages,  owing  to  the  fact  that  aluminum  is  pure 
and  safe,  no  returning  is  required,  and  there  is  absolutely  no  danger  of  any  formation 
of  verdigris,  food  discoloration,  food  contamination,  or  metal  poisoning. 

Few  fruit  or  vegetable  acids  which  occur  in  ordinary  cooking  have  any  effect 
on  aluminum.  Some  acids  do  act  on  the  metal,  however;  it  is  dissolved  by  hydro- 
chloric or  muriatic  acid,  and  sulphuric  and  nitric  acid  act  on  it  slightly;  it  is  corroded 
by  solutions  of  caustic  alkali.  Sonic  alkaline  waters  discolor  the  metal,  but  this 
discoloration  is  harmless,  can  he  easily  removed  by  any  good  scouring  material. 
and  has  no  injurious  effect  upon  the  kettle  unless  the  discoloration  amount-  to  n 


570  OPERATION   OF   THE    HOSPITAL 

corrosion,  or  the  discoloration  takes  place  so  frequently  as  to  wear  out  the  utensil 
in  scouring.  Aluminum  utensils  should  be  made  of  sheet  metal  rather  than  of  cast; 
the  metal  should  be  pure,  rolled  hard,  and  not  annealed.  Where  an  aluminum  uten- 
sil pits  it  is  usually  due  to  impure  metal  or  an  imperfection. 

Pure  aluminum  does  not  make  a  good  casting,  because  it  becomes  more  or  less 
porous,  and  should  not  be  used  for  utensils  in  which  food  is  cooked.  There  is  no 
objection  to  using  a  cast  vessel  for  boiling  water  or  frying  meats,  although  sheet 
utensils  used  for  the  same  purpose  are  superior  if  they  are  of  the  proper  thickness, 
purity,  and  hardness. 

Because  of  the  difficulty  in  having  steam-jacketed  kettles  returned  aluminum 
is  especially  adapted  for  such  utensils,  inasmuch  as  it  needs  no  coating  of  tin;  an 
aluminum  kettle  properly  made  should  give  constant  service  without  repairs. 

THE  PURCHASE  OF  CUTLERY  AND  SILVERWARE 

In  the  purchase  of  cutlery  and  silverware  for  institution  use  the  prime  considera- 
tion is  to  obtain  the  best  looking  stuff,  and  that  will  preserve  its  good  appearance 
for  the  longest  time  for  the  least  money.  The  ordinary  table  knife  has  many  uses 
in  the  hospital  besides  the  purpose  for  which  it  was  originally  intended.  The 
nurses  and  hospital  help  use  the  knife,  and  sometimes  the  fork  or  spoon,  to  pry  open 
things,  to  open  windows  that  are  stuck,  and  they  sometimes  stick  them  under  the 
door  to  keep  it  from  slamming.  There  may  be  tools  in  the  institution  for  these 
various  purposes,  but  nothing  seems  to  be  so  handy  for  the  nurse  as  a  table  knife  or 
fork,  and  certainly  nothing  seems  to  have  so  many  uses  aside  from  the  legitimate 
one.  It  is  useless,  therefore,  to  buy  cutlery  that  costs  very  much  money.  It  is 
even  useless  to  buy  knives  on  which  an  edge  can  be  put,  because  they  will  never  be 
in  decent  shape  at  the  best,  and  the  money  put  into  good  steel  is  wasted.  About 
the  best  knife  that  can  be  bought  is  one  piece,  cast  steel,  plated  with  two  or  three 
or  four  coats  of  silver  or  even  German  silver.  A  very  good  institution  knife  can 
be  purchased  for  $1.75  or  $2  per  dozen,  and  if  the  institution  is  convenient  to  a 
plating  establishment  the  knife  can  be  resilvered  at  an  inconsequential  expense. 
First-class  restaurants  have  a  few  good  steel  knives  that  are  kept  in  good  order, 
and  these  are  distributed  as  an  extra  order  of  cutlery  to  people  who  order  steaks. 
If  this  plan  is  adopted  it  will  be  unnecessary  to  have  the  knives  in  general  use 
sharpened  to  an  edge. 

Precisely  the  same  conditions  operate  in  the  case  of  the  silverware,  forks,  and 
spoons.  Forks  and  the  larger  spoons  can  be  purchased  in  quadruple  plate  of  Ger- 
man silver  for  $1.25  a  dozen,  and  if  purchased  from  a  reliable  firm  that  has  actually 
put  four  coats  of  alloy  on  them,  the  article  will  be  broken  up  by  the  household  help 
long  before  the  plating  wears  off. 

For  serving  the  interns,  nurses,  and  the  help  china  or  porcelain  sugar  bowls  and 
creamers  and  individual  coffee  and  tea  pots  are  used,  and  they  are  cheaper,  and 
require  very  much  less  attention  than  silver  or  plated  ware,  but  it  will  be  neces- 
sary to  have  a  certain  amount  of  silver  or  plated  ware  in  these  articles  to  serve 
private  patients.  Nothing  dresses  a  tray  quite  so  well  as  pretty  sugar  bowls  and 
creamers  and  nice  looking  silverware,  but  if  we  use  these  articles  in  expensive  ware 
we  come  upon  a  unique  difficulty.  Hotels  and  restaurants  are  troubled  a  great  deal 
with  souvenir  hunters,  but  this  is  truer  even  in  hospitals.  It  is  almost  impossible 
to  keep  attractive-looking  individual  sugar  bowls  or  creamers  in  the  private  depart- 
ments of  a  hospital.  Patients'  friends  think  it  is  perfectly  legitimate  to  carry  away 
as  a  souvenir  any  little  silver  article  that  happens  to  attract  their  attention.     If 


PURCHASE    OF   SUPPLIES 


571 


they  are  small,  daintily  made,  and  odd  shaped,  so  much  the  more  reason  why  they 
will  be  carried  away.  If  they  are  coarse  looking,  unattractive,  and  badly  plated, 
the  institution  suffers  in  the  poorly  set  tray.  So  we  are  between  the  two  horns  of 
a  dilemma.     About  the  only  cure  for  this  combination  of  troubles  is  in  a  recently 


Fig.  194. — Combination  coffee  pot,  creamer,  and  sugar  bowl. 

designed  article,  which  is  a  combination  of  coffee  or  tea  pot,  creamer,  and  sugar 
bowl.  This  article  is  shown  in  Figs.  194  and  195.  It  has  two  advantages — one, 
that  it  is  large  enough  to  prevent  its  going  into  the  pocket  of  the  souvenir  hunter ; 
and,  second,  that  it  takes  up  less  room  on  the  tray,  because  it  is,  in  effect,  three 


Fig.  195. — Combination  set. 


stories  high.  This  little  article  is  made  in  almost  any  combination  of  silver,  either 
sterling,  quadruple,  or  triple  plate,  and  costs  in  proportion.  They  can  be  bought 
in  dozen  lots  at  almost  any  large  dealer's  for  $1.75  each  in  substantial,  heavy 
plate. 


572  OPERATION   OF   THE    HOSPITAL 

THE  PURCHASE  OF  CHINA  AND  GLASSWARE 

These  table  articles  are  rather  a  matter  of  choice  than  otherwise.  We  are 
told  by  dealers  that  a  certain  kind  of  ware  will  last  longer  than  another,  and  that 
it  will  not  break  when  it  falls,  that  it  will  not  break  in  hot  water,  and  that  it  will 
not  chip  in  the  rough  handling  of  washing.  We  try  to  make  ourselves  believe  in 
these  virtues,  and,  with  each  recurring  order  of  new  dishes,  we  feel  that  perhaps  we 
have  solved  the  question  of  china  breakage,  only  to  be  shocked  a  few  weeks  later 
with  a  notice  that  we  are  again  out  of  dishes.  There  is  no  dish  made  that  can  be 
dropped  on  the  floor  without  breaking;  there  is  no  dish  made  that  will  not  chip  under 
the  gentle  handling  of  an  athletic  dishwasher.  Sometimes  we  buy  thin  china  dishes 
in  the  expectation  that  they  are  stronger  than  the  heavy  stone  ware,  but  they  all 
break  in  about  the  same  length  of  time  under  the  same  conditions,  and  about  the 
only  question  for  serious  consideration  in  the  purchase  of  dishes  is  whether  we  are 
willing  to  pay  more  for  a  better  looking  article  that  will  last  about  the  same  length 
of  time  as  a  cheaper  one.  The  cheaper  the  article  we  purchase,  the  more  money  we 
will  be  ahead  at  the  end  of  the  year,  and  such  economies  can  well  be  practised  with 
the  common  help,  and  to  a  certain  extent  with  the  interns,  nurses,  and  executive 
officers'  tables.  But  we  must  pay  for  style  in  providing  for  the  trays  of  private 
patients.  Perhaps  the  rolled-rim  dish  will  chip  a  little  less  easily  than  the  flat  rim, 
but  that  is  about  the  only  advantage  in  one  kind  of  dish  over  another. 

In  some  institutions  quite  an  efficient  method  is  practised  to  limit  the  breakage 
of  dishes,  and  that  is  to  compel  the  breaker  to  pay  for  them.  The  breakage  of 
dishes  was  cut  more  than  one-half  in  the  Michael  Reese  Hospital  when  the  board  of 
directors  permitted  a  rule  compelling  nurses  and  maids  to  pay  for  the  dishes  they 
broke. 

The  careful  monograming  and  marking  of  dishes  will  decrease  the  breakage  if 
a  head  nurse  is  given  a  complete  supply  of  chinaware  all  containing  her  own  special 
mark;  that  is,  the  number  of  the  floor  or  service  or  ward,  in  addition  to  the  mono- 
gram of  the  institution ;  and  she  will  not  be  able  to  accuse  other  people  in  the  house 
of  having  appropriated  her  dishes;  and  if  some  pieces  are  taken  she  can  recover 
them.     A  good  deal  of  moral  force  also  is  contained  in  this  fixing  of  responsibility. 

About  the  only  detail  of  marking  and  monograming  that  is  entitled  to  considera- 
tion is  the  question  of  gilt.  Ordinary  colored  markings  are  manufactured  in  the 
body  of  the  ware,  and  the  ware  is  then  glazed  over,  but  gilt  is  overlaid  in  the 
glaze  itself  and  will  soon  wear  off.  It  is,  therefore,  not  desirable  as  an  ornament  to 
any  chinaware. 

Drinking  glasses  come  under  the  same  consideration  as  china.  The  cheap, 
heavy  stuff  breaks  as  easily  if  the  temperature  of  the  water  is  very  suddenly  changed; 
that  is,  if  the  glass  contains  cold  water,  and  that  is  poured  out,  and  the  glass  im- 
mediately filled  with  hot  water,  there  is  not  enough  elasticity  in  the  substance  of 
the  glass  to  stand  the  expansion,  and  there  is  a  crack  which  continues  until  the  glass 
is  broken.  The  heavy,  cheap  glass  will  stand  more  rough  usage,  temperature  ex- 
cepted, than  the  thin  fine  stuff,  and  a  jar  that  will  break  the  thin  glass  will  often- 
times not  break  the  heavy  one.  But  thin  ware  will  stand  alternate  hot  and  cold 
water  much  better,  and  the  thin  article  is  very  much  the  pleasanter  to  use.  Then 
too,  there  are  a  good  many  people  who  feel  that  a  thick,  cheap  glass  is  not  worth 
being  careful  with,  and  they  seem  to  handle  it  roughly  on  purpose,  whereas  if  the 
glass  is  thin,  and  especially  if  it  has  a  pretty  monogram,  they  will  be  more  careful 
with  it,  so  that  in  the  long  run  it  is  very  doubtful  whether  the  institution  will  be 
out  any  money  at  the  end  of  the  year  by  purchasing  the  better  grades  of  glassware. 


PURCHASE   OF   SUPPLIES  573 


PURCHASE  OF  SOAPS 


The  institution  buyer  is  almost  absolutely  helpless  when  it  comes  to  purchasing 
soaps.  In  nearly  every  other  commodity  there  is  something  in  the  appearance, 
smell,  or  taste  that  will  give  a  clue  to  quality  and  character.  But  soap  makers 
have  learned  to  deceive  in  all  these  particulars,  and  with  soap  the  old  adage  is  espe- 
cially true  that  "all  that  glitters  is  not  gold."  There  are  two  ways  to  buy  soaps — 
on  the  honor  of  the  maker  as  to  true  soap  content,  or  by  chemic  analysis,  which  is 
the  far  safer  way.  In  analyzing  soap  three  things  must  be  sought — the  percentage 
of  water,  because  water  at  soap  prices  is  not  a  profitable  commodity;  adulterants, 
for  the  same  reason;  and  the  litmus  reaction,  because  alkalinity  or  neutrality  is 
desirable  always  and  absolutely  necessary  sometimes. 

Soaps  should  be  divided,  according  to  their  methods  of  manufacture,  into  two 
general  classes,  boiled  and  semiboiled  or  cold  made.  In  the  boiled  soap  the  fat 
and  alkali  are  boiled  together  to  complete  saponification,  and  the  soap  salted  out 
from  the  excess  of  alkali  and  glycerin  which  has  been  separated.  This  soap  base 
may  be  used  for  the  manufacture  of  laundry  or  toilet  soap,  depending  upon  the 
quality  of  stock  used  in  its  manufacture.  The  cold-made,  or  semiboiled  soaps, 
are  made  by  mixing  the  theoretic  quantities  of  fat  and  alkali  together  and  allowing 
saponification  to  proceed  slowly.  Included  in  this  class  are  some  cheaper  grades 
of  toilet  soap,  practically  all  potash  soaps,  meaning  the  green  soft  soaps,  and  some 
cheaper  grades  of  heavily  filled  laundry  soaps,  chip  or  bar. 

Any  soap  must  be  considered  from  its  actual  true-soap  content,  which  is  a 
chemic  combination  of  alkali  with  fat.  Fat,  as  we  know  it,  is  a  glycerid  or  a 
chemic  compound  of  fatty  acids  with  glycerin.  Under  proper  conditions,  alkali 
will  split  off  this  glycerin  and  take  its  place,  leaving  a  new  compound,  a  salt  of  the 
fatty  acids  and  alkali,  present,  or  soap,  the  glycerin  remaining  free  in  the  soap  unless 
separated  by  some  process  of  manufacture.  On  this  basis  it  is  possible  to  judge  the 
merit  of  soap  of  any  description  and  for  any  purpose.  Soaps  for  special  purposes 
are  made  by  selecting  the  fat  and  the  alkali  to  be  used;  that  is,  there  is  a  choice  in 
fats  of  tallows,  greases,  or  vegetable  oils;  in  alkalis,  of  soda  or  potash.  There  are 
other  things  mixed  with  soap  other  than  true  soap,  which  are  not  added  for  adul- 
terating purposes  unless  present  in  excessive  amounts.  For  instance,  soaps  used 
in  extremely  hard  water  must  contain  a  certain  percentage  of  free  alkaline  carbon- 
ate, or  similar  material,  to  aid  in  softening  the  water. 

Adulterations. — Adulterants  of  soap  are  usually  in  the  nature  of  fillers  or  make- 
weights; the  idea  is  not  to  pay  for  make-weights  or  fillers  at  soap  prices;  silica  can 
be  bought  for  a  song,  but  tallow  and  vegetable  oils  cost  money;  but  it  is  not  always 
easy  to  draw  the  line  where  adulteration  commences  and  ends.  Pure  soaps  cost 
more  because  the  user  is  allowed  to  fill  his  own  soaps  at  filler  prices  to  suit  his  own 
conditions,  but  in  selling  to  private  families  that  have  no  facilities  and  cannot  buy 
soap  on  a  sufficiently  large  scale  to  permit  them  to  make  their  own  solutions,  the 
filler  is  added  to  give  the  best  general  working  combination.  If  the  quantities 
of  alkali  in  bar  soap  are  excessive,  they  have  been  added  for  the  purpose  of  carrying 
additional  water,  that  is,  say  the  soap  normally  runs  3  to  10  per  cent,  of  free  alkali 
in  the  soap,  for  every  additional  percentage  of  alkali  a  correspondingly  larger 
percentage  of  water  can  be  carried,  which,  of  course,  diminishes  the  true  soap  value 
and  adds  the  weight  of  the  water.  It  is  impossible  to  determine  the  amount  of 
moisture  in  a  soap  by  its  appearance  or  "feel."  For  instance,  some  apparently 
dry-chip  soaps  have  more  than  an  average  amount  of  moisture,  say  12  per  cent., 
but  the  moisture  is  concealed  as  a  water  of  crystallization  of  sonic  alkaline  filler. 


574  OPERATION   OF   THE    HOSPITAL 

The  moisture  in  the  cheapest  bar  laundry  soap  will  run  about  28  per  cent.;  in  green 
soap,  45  or  50  per  cent.,  depending  on  the  nature  of  the  soap;  35  per  cent,  of  moisture 
may  be  made  to  look  like  28  per  cent.,  and  60  per  cent,  made  to  look  like  50  per  cent, 
by  an  excess  of  alkali,  and  in  the  added  moisture  we  pay  for  water  at  the  price  of 
soap. 

Samples  should  be  analyzed  for  the  amount  of  true  soap,  or  the  percentage  of 
fatty  acids  and  combined  alkali ;  the  sum  of  these  two  is  the  true  soap,  which  is  the 
only  part  of  the  soap  that  has  any  cleansing  properties,  with  the  exception  of  the 
free  alkali,  which  can  be  bought  at  a  cheaper  price  and  added — in  the  laundry,  for 
instance. 

Rosin  forms  an  alkaline  salt  which  is  similar  to  soap,  and  is  a  necessary  part  of 
some  soaps,  as  it  is  added  to  tallow  soaps  to  increase  their  solubility.  The  greatest 
use  of  rosin  is  in  the  common  bar  rosin  soaps. 

Free  mineral  grits,  which  are  usually  silica,  talc,  volcanic  ash,  pumice,  or  marble 
dust,  are  usually  adulterants;  fillers  of  this  sort  are  only  of  value  in  scouring  soaps; 
in  soaps  for  washing  purposes  they  are  simply  added  for  weight. 

Adulterants  That  Have  No  Value. — The  principal  worthless  adulterant  is  starch; 
this  not  only  adds  its  own  weight,  but  has  the  capacity  to  carry  additional  water. 
Talc  enters  this  same  class,  as  it  has  very  little  scouring  property. 

Relative  Value  of  Soap,  or  True  Soap  Content,  in  Money. — Take,  for  instance, 
this  illustration:  "A"  soap  costs  1\  cents  per  pound;  "B"  soap  costs  6  cents  per 
pound;  on  analyzing,  we  find  that  "A"  soap  contains  88  per  cent,  of  true  soap; 
"B"  soap  contains  65  per  cent. ;  dividing  65  by  88,  and  multiplying  by  100,  we  get 
about  74,  the  percentage  value  that  "B"  is  of  "A."  Taking  this  percentage  of  1\  we 
find  that  "B"  should  only  cost  5.36  cents  per  pound,  because  of  the  small  amount 
of  true  soap  that  is  in  it.  Looking  at  it  in  another  way,  soap  "A"  is  costing  7| 
cents  per  pound,  or  $7.50  per  100  pounds.  In  soap  "A"  there  are  88  pounds  of 
true  soap.  Then  each  pound  of  true  soap  will  cost  $7.50,  divided  by  88  pounds,  or 
8|  cents.  Soap  "B"  is  costing  6  cents  per  pound,  or  $6  per  100  pounds,  and  con- 
tains only  65  per  cent,  of  true  soap,  so  per  pound  of  true  soap  it  will  cost  $6,  divided 
by  65,  or  9j  cents.  So  it  is  seen  that  the  true  soap  (the  part  wanted)  can  be  obtained 
for  less  money  by  buying  the  more  expensive  chip. 

Steam  Laundry  Soaps. — For  laundry  purposes  a  chip  soap  is  to  be  preferred;  the 
chip  soap  is  much  more  conveniently  handled,  because  laundry  soaps  must,  in  any 
event,  be  dissolved  before  using,  and  the  chip  soap  dissolves  much  more  readily 
than  bar.  It  is  quite  easy  to  obtain  chip  soap  containing  no  filler  whatever,  while 
practically  all  bar  soaps  contain  a  certain  percentage  of  filler  in  the  shape  of  free 
alkaline  salts,  such  as  soda  ash.  This  can  be  bought  cheaper,  and  added  by  the 
laundryman  to  suit  the  special  conditions  of  the  laundry.  There  is  another  point 
— practically  all  bar  soaps  are  rosin  soaps;  this  rosin  has  a  soap  value,  as  before 
stated,  but  is  not  considered  equal  to  that  of  tallow,  and  is  added  to  the  tallow  bar 
soap  to  make  it  more  soluble,  and,  therefore,  more  satisfactory,  since  the  tallow 
or  chip  soap  is  easily  dissolved,  there  is  no  need  of  this  percentage  of  rosin  being 
present,  and  we  get  the  full  value  of  the  fatty  stock  as  against  rosin,  so  that, 
pound  for  pound,  though  apparently  much  more  expensive,  the  chip  soap  will  be 
cheaper  in  the  end. 

This  chip-soap  solution,  which  we  have  described  for  steam  laundry  purposes, 
may  be  also  used  quite  as  economically  for  whatever  hand  work  there  may  be  to  do 
in  the  steam  laundry  wherever  there  is  a  sufficient  amount  of  work  to  justify  making 
it  up.  This  chip-soap  solution  is  being  used  in  many  places  advantageously  and 
economically  for  dishwashing  purposes,  and,  where  the  use  of  it  can  be  controlled 


PURCHASE    OF    SUPPLIES  575 

at  all,  it  will  no  doubt  be  cheaper  than  bar  soap  for  this  purpose;  the  chief  dis- 
advantage in  the  use  of  this  soap  for  dishwashing  purposes  is  that  maids  are  dis- 
posed to  use  too  much  of  it  unless  they  are  watched,  but  this  fault  can  be  coun- 
ter-balanced by  cutting  the  amount  of  soap  in  the  solution;  that  is,  by  making  it 
thinner. 

Soap  Powders  and  Scouring  Powders.— Soap  powder  is  a  mixture  of  sodium 
carbonate  or  commercial  soda  ash  and  soap  finely  powdered,  with  moisture  added. 
It  is  a  handy  and  strongly  alkaline  soapy  cleansing  mixture,  its  value  being  based 
upon  the  content  of  true  soap  and  of  sodium  carbonate,  and  also  upon  the  fineness 
of  the  powder,  because  of  the  greater  readiness  with  which  it  goes  into  solution. 
Sometimes  soap  powders  are  found  in  which  the  soap  is  present  in  hard  granular 
kernels,  which  are  rather  slow  in  going  into  solution;  in  a  good  soap  powder  it  should 
be  practically  impossible  to  distinguish  between  the  grains  of  soda  ash  and  soap 
with  the  naked  eye. 

The  best  scouring  powders  are  composed  of  well-selected  clean  mineral  grit, 
sharp  enough  to  cut  the  stains  and  dirt  and  not  hard  enough  to  scratch,  combined 
with  a  small  percentage  of  free  alkali  and  soap  to  emulsify  any  greasy  matter. 
These  should  not  be  mistaken  for  washing  powders,  and  are  to  be  used  with  a  mini- 
mum quantity  of  water,  and  not  flooded,  as  in  the  use  of  soap  washing  powders. 
One  of  the  common  mistakes  of  people  in  the  use  of  scouring  powders  is  that  they 
use  too  much  water  and  flood  the  powder,  and  thus  destroy  its  scouring  property. 
It  is  a  common  mistake  in  hospitals  to  throw  the  used  water  with  scouring  powder 
into  the  basins  and  closets,  which,  on  account  of  the  insolubility  of  the  particles 
it  contains,  has  the  effect  of  clogging  the  plumbing. 

Cheap  powders  are  apt  to  contain  harsh  and  injurious  particles  which  scratch 
the  floors  and  marble,  wear  them  out  quickly,  and  are  very  apt  to  contain  unrefined 
minerals,  which  leave  dirty  marks  in  their  wake;  these  cheap  powders  also  are 
apt  to  have  in  them  large  quantities  of  tailings  of  grit,  which  weigh  and  cost  money, 
and  the  particles  are  so  fine  that  they  are  practically  useless  for  scouring  purposes. 

Green  Soaps. — The  so-called  green  oil  soaps  may  be  divided  into  two  classes — 
(1)  those  to  be  used  strictly  for  surgical  purposes,  and  (2)  the  commoner  soaps 
for  woodwork  and  other  cleaning  about  the  institution.  All  so-called  green  oil 
soaps  are  essentially  potash  soaps,  whereas  the  toilet  soaps  and  laundry  soaps 
are  soda  soaps. 

The  surgical  green  soaps  are  made  according  to  the  U.  S.  P.,  under  the  Pure 
Drug  Law,  which  calls  for  linseed  as  the  fat  constituent.  It  may  be  doubted  whether 
linseed  oil  has  any  value  over  cotton-seed  oil,  the  new  Soya  bean  oil  that  is  just 
coining  into  use,  corn  oil,  or,  if  they  were  not  too  expensive,  the  olive  oils;  it  is 
probable  the  Pharmacopoeia  originally  specified  linseed  oil  because  there  was  no 
cotton  or  corn  oil. 

The  surgical  soaps  usually  contain  50  per  cent,  of  water,  and  the  Pharmaco- 
poeia  requires  a  slight  excess  of  alkali.  The  other  50  per  cent,  is  made  up  of  fats 
in  the  shape  of  linseed  oil  and  potash,  together  with  a  little  free  potash,  to  comply 
with  the  Pharmacopoeia  requirement  of  an  alkaline  excess.  Very  frequently  manu- 
facturers color  their  surgical  soaps  with  grass  coloring-matter  to  give  them  a  rich 
green  appearance,  and  this  adulterant  stains  whatever  it  conies  in  contact  with. 
True  green  oil  soaps  are  not  green  at  all,  and  certainly  not  bright  green;  they  are 
amber,  with  a  very  faint  suspicion  of  a  greenish  tinge,  if  any  olive  oil  has  been  used 
in  their  manufacture. 

The  cheaper  soaps  are  practically  t  lie  same  composition,  with  the  exception  thai 
the  Fats  are  of  cheaper  grades,  not  so  well  refined;  and  there  is  occasionally  a  per- 


576  OPERATION    OF   THE    HOSPITAL 

centage  of  rosin,  which  is  of  no  particular  value,  though  not  considered  adulterant, 
but  merely  a  cheaper  form  of  necessary  stock.  In  purchasing  these  cheaper  forms 
of  green  oil  soap  for  the  commoner  purposes  of  the  hospital  there  is  danger  of 
paying  for  a  large  excess  of  rosin  at  a  price  that  ought  to  buy  a  better  stock;  usually 
these  cheaper  green  soaps  are  also  filled  with  an  excess  of  alkali  in  the  shape  of 
free  alkaline  salts;  even  a  part  of  the  potash  is  occasionally  replaced  by  soda, 
which  tends  to  harden  the  soap  and  make  it  carry  more  water. 

In  either  of  these  classes  of  potash  soaps  the  body,  or  hardness  of  the  soap, 
cannot  be  taken  as  an  indication  of  the  moisture  content,  because  a  solid  fat  will 
give  a  much  harder  soap  than  liquid  fat,  the  moisture  content  being  the  same. 
For  instance,  tallow  as  a  fat  basis  would  make  a  very  much  harder  soap  than  the 
same  proportion  of  cotton-seed  oil,  and  the  tallow  soap  might  be  watered  a  great 
deal  more  and  still  appear  as  a  richer  soap,  whereas  one  is  paying  for  a  large  quan- 
tity of  water  at  soap  prices. 

Uses  of  Green  Oil  Soaps. — Green  oil  soap  can  be  used  to  clean  painted  and 
varnished  surfaces  without  injury.  The  best  method  for  painted  walls  and  ceil- 
ings is  to  make  an  emulsion,  by  cooking  for  about  an  hour  1  pound  of  green  oil 
soap  in  4  gallons  of  water;  apply  this  emulsion  with  a  sponge  to  the  surface  and 
immediately  wash  off  with  clean  water,  and  wipe  dry  with  a  damp  cheese-cloth  or 
chamois.  The  result  will  be  a  bright  and  almost  new  appearance.  A  very  dirty 
wall  may  require  a  second  light  cleaning  with  a  little  green  suds;  always  clean 
walls  working  from  bottom  up  to  prevent  streaking  with  dirty  water. 

To  clean  furniture  and  varnished  woodwork  it  is  best  to  first  cook  up  the  green 
oil  soap,  and  then  make  the  required  soapsuds  strength  from  this  soap  stock. 
The  most  economic  way  to  use  green  oil  soap  for  scrubbing  hardwood,  linoleum, 
mosaic,  and  made-marble  floors  is  first  to  make  up  a  soap  stock — i.  e.,  1  part  soap 
and  6  parts  water,  and  add  a  little  soda  or  washing  powder  to  give  it  added  alka- 
linity.    Use  a  half-pint  of  this  to  a  scrub  pail  to  make  the  suds. 

Toilet  Soaps. — Castile  Soap. — Toilet  soap  for  institution  purposes  may  be  di- 
vided into  two  classes,  one  for  use  on  the  delicate  skin  of  infants  and  for  bath  purposes 
of  the  sick,  where  a  soap  of  great  softness  and  mildness,  combined  with  great  cleans- 
ing properties,  is  essential.  For  such  purposes  the  olive  oil  soaps  stand  alone.  It 
must  be  understood  that  all  olive  oil  soaps  are  Castile  soaps,  but  all  Castile  soaps  are 
not  olive  oil.  Genuine  Castile  soap  is  made  abroad  and  imported  in  the  shape  of 
soap;  it  can  then  be  cleaned  of  filth  and  extraneous  matter,  milled,  and  reshaped. 
Due  to  trade  conditions  it  is  practically  impossible  to  get  the  right  quality  of  oil 
in  this  country  for  making  the  best  grades  of  olive  oil  soaps,  so  that  it  is  frequently 
found  that  domestic  Castile  soaps,  if  made  from  olive  oil  at  all,  contain  only  the 
lower  grades  or,  more  frequently,  only  olive  oil  substitutes;  that  is,  other  vegetable 
oils. 

Other  Toilet  Soaps. — The  second  class  of  toilet  soaps  may  be  subdivided  into 
three  classes:  first,  milled  soap;  this  is  soap  which,  after  saponification,  has  been 
dried  and  then  milled,  perfumes  being  added  in  the  milling.  This  milling  process 
is  one  of  the  finest  mixing,  and  might  be  explained  by  describing  the  machine, 
which  is  composed  of  granite  rolls,  revolving  very  closely  together,  the  soap  being 
forced  to  pass  between  these  rolls  in  a  plastic  state;  this  process  kneads  the  soap 
into  a  homogeneous  mass.  Such  soaps  are  usually  very  low  in  moisture,  not  run- 
ning over  10  or  12  per  cent.  This  process  is  used  for  all  higher  grade  soaps,  one 
reason  being  that  the  more  delicate  perfumes  can  be  worked  into  the  soap  cold, 
while  if  such  perfumes  were  added  to  a  hot  soap  they  would  be  destroyed.  The 
base  of  this  milled  soap  is  the  same  as  any  soda  soap,  that  is,  any  animal  or  vegetable 


PURCHASE    OF   SUPPLIES  5/7 

fats.  During  this  process  of  milling  any  medicament  may  be  incorporated  to  make 
the  medicated  soaps,  and  any  colors  are  usually  added  in  at  the  same  time,  also 
such  fillers  as  starch. 

The  second  class  is  composed  of  the  floating  soaps;  these  are  soda  soaps,  usually 
running  fairly  high  in  vegetable  oils,  especially  cocoanut;  the  property  of  floating 
is  obtained  by  simply  churning  air  into  the  mass  while  the  soap  is  in  a  liquid  state, 
anil,  of  course,  milling  as  in  the  above  class  is  entirely  out  of  the  question,  as  this 
would  again  release  the  air;  these  soaps  carry  a  large  moisture  content,  about  25 
per  cent. 

The  third  class  is  the  so-called  semiboiled,  or  cold-made  soaps,  in  which  the 
alkaline  and  fat,  perfume,  and  any  other  ingredients  are  simply  mixed  together  in 
theoretic  proportions  and  the  saponification  allowed  to  proceed  slowly.  Practi- 
cally, all  transparent  soaps  are  of  this  class.  The  danger  with  this  class  of  soaps  is 
from  improper  mixing;  that  is,  the  addition  of  too  little  or  too  much  alkali  for  the 
amount  of  fat  present,  which  means,  of  course,  free  fat  in  the  soap,  or  an  excess  of 
free  alkali,  and  the  saponification  is  apt  to  be  incomplete. 

PURCHASE  OF  JANITORS'  SUPPLIES 

The  most  destructive  and  careless  people  in  the  world  are  institution  common 
help.  The  wages  for  such  service  as  scrubbing  floors  and  washing  windows,  walls, 
and  woodwork  are  necessarily  low,  and  hence  the  mental  caliber  of  such  servants 
is  almost  a  negligible  quantity.  It  naturally  follows  that,  in  the  purchase  of  sup- 
plies for  such  people  to  use,  the  prime  considerations  must  be,  first,  that  the  article 
will  do  the  work  quickly  with  the  least  amount  of  labor,  and,  second,  that  it  shall 
be  as  nearly  indestructible  as  possible.  It  is  not  a  question  of  how  cheap  an  article 
is  as  to  first  cost,  but  how  cheap  it  is  considering  the  work  it  has  to  do  and  the 
length  of  time  it  will  last. 

Another  most  important  consideration  just  here  is  the  method  of  distribution 
of  janitors'  supplies  and  the  system  by  which  the  most  possible  work  can  be  got  out 
of  an  article.  For  instance,  it  would  be  folly  to  compel  a  maid  to  use  a  corn  broom 
on  fine  carpeting  after  it  had  been  worn  down  almost  to  the  wire  binding.  The  wear 
on  a  carpet  swept  with  such  a  broom  would  be  far  greater  than  the  foot-wear.  But 
such  a  broom  will  answer  well  for  sweeping  out  the  laundry  or  power  house,  or  in 
the  yardman's  department.  The  same  rule  would  apply  to  mops  and  scrubbing 
brushes.  To  tiring  about  a  proper  exchange  of  such  articles  there  should  be  a  regu- 
lar and  pretty  rigid  system  of  distribution.  First,  there  should  be  some  fixed  and 
well-known  hour  and  day  on  which  supplies  should  be  drawn,  and  anything  wanted 
in  emergency  should  be  subject  to  a  good  deal  of  "red  tape,"  to  impress  on  the 
minds  of  the  people  the  necessity  to  observe  the  time  rule. 

Every  servant  who  asks  for  a  new  article  should  be  compelled  to  bring  in  the 
old  one,  or  its  skeleton,  or  to  go  through  a  catechism  as  to  its  whereabouts  in  the 
event  it  cannot  be  produced;  then  the  head  janitor  or  storekeeper  can  determine 
whether  the  article  is  past  further  usefulness  in  the  hands  of  that  particular  servant 
and  whether  it  can  be  used  elsewhere.  Besides,  if  the  return  of  worn-out  articles 
is  insisted  upon,  there  will  lie  fewer  articles  stolen  by  the  help  and  taken  from  the 
premises,  ami  an  article  will  often  be  used  much  longer,  because  servants  are  very 
fond  of  new  things  to  work  with,  and  will  often  throw  away  very  slightly  worn 
tools.  Sometimes  they  will  actually  complete  the  destruction  of  an  article  just 
to  get  a  new  one;  a  good  janitor  can  frequently  tell  by  the  look  of  an  article  whether 
it  has  actually  been  worn  out  or  broken  up. 


578  OPERATION    OF   THE    HOSPITAL 

Mops  and  Pails. — The  most  important  articles  in  the  janitor's. department 
are  the  mops  and  pails.  Let  us  first  see  whether  and  where  we  are  going  to  use  mops. 
In  the  old  days  of  institution  construction  there  was  much  soft-wood  flooring  and 
other  woodwork.  Generally  varnish  was  used  when  the  buildings  were  constructed, 
but  this  soon  wore  off  the  floors  and  the  bare  wood  grain  was  exposed.  Noth- 
ing will  clean  unvarnished  or  unwaxed  wood  but  a  hand  scrub  brush,  a  powerful 
arm  at  the  end  of  a  supple  back,  and  plenty  of  hot  water  and  strong  lye  soap. 

But  there  is  too  much  floor  space  in  institutions  nowadays,  and  help  costs  too 
much  to  justify  the  time  and  labor  of  hand  scrubbing;  moreover,  most  floors  are 
made  of  concrete  or  marble,  which  do  not  require  such  hard  work  in  cleaning,  or 
hardwood,  with  heavy  shellac  and  varnish  or  wax  finish,  which  cleans  very  readily 
and  very  adequately  with  a  damp  or  even  dry  cloth.  About  the  only  thing  hand 
scrubbing  and  hot  lye  soap  water  will  do  to  a  varnished  floor  that  a  damp  mop  will 
not  do  is  to  take  the  varnish  or  wax  off.  There  are  still  some  places  that  require 
hand  scrubbing,  mostly  hallways,  that  cannot  be  covered  with  linoleum  and  that 
are  too  much  used  to  justify  frequent  varnishing,  kitchen  tables,  drain  boards,  and 
pantry  shelves.  But  the  hardwood  floors  of  private  rooms  and  wards  and  the 
marble,  mosaic,  or  concrete  or  corridors  and  service  rooms  can  be  kept  quite  clean 
with  a  carefully  used  mop. 

Nothing  gives  to  a  room  or  corridor  so  untidy  an  appearance  as  strings  of  mop 
cotton  stuck  into  cracks  or  about  furniture  feet,  stair-rails,  and  door-steps;  this 
comes  from  using  the  cheap  mop  twine,  which  is  practically  a  cotton  waste  with 
so  short  a  fiber  that  it  comes  apart  on  the  slightest  pull  after  a  few  hours  of  wetting. 
These  cheap  mops  cost  about  $25  to  $30  a  gross,  or  from  15  to  20  cents  each,  ac- 
cording to  the  weight.  There  is  another  mop  of  long-fiber  cotton  twine  that  costs 
50  cents,  but  one  such  will  wear  longer  than  a  dozen  cheap  ones,  and  in  the  course 
of  the  year  will  be  vastly  cheaper  to  use. 

Some  day  some  one  will  devise  a  mechanical  mop  pail  that  will  perform  the 
service  needed  and  make  a  great  feature;  there  is  none  on  the  market  now  that  is 
satisfactory.  The  mechanism  that  locks  the  mop  in  the  pail  between  the  rollers, 
which  releases  it  by  a  dead  pull  on  the  handle  is  the  worst,  because  it  tears  the  mop 
to  pieces  quickly.  The  one  that  requires  the  operator  to  hold  his  foot  on  the 
wringer  lever  while  he  turns  the  wringer  rolls  by  a  handle  is  just  a  little  better, 
because  it  takes  a  carefully  adjusted  foot-pressure  to  do  the  trick. 

Brooms  and  Dusters. — As  we  have  seen  in  our  section  under  Equipment  on  the 
subject  of  vacuum  cleaners,  there  is  no  tool  concerned  in  vacuum  cleaning  that  will 
take  the  place  of  the  old-fashioned  corn  broom  for  bare  floors  and  cracks,  but  the 
vacuum  cleaner  ought  to  be  used  as  much  as  possible  and  wherever  possible,  in 
order  that  the  dust  may  be  actually  picked  up  and  carried  out,  and  not  scattered 
about  to  fall  in  some  place,  perhaps  on  an  open  wound,  or  be  inspired  by  the 
patient  or  attendants.  Brooms  and  clusters  are  poor  things  in  a  hospital,  and 
especially  dusters.  There  are  many  places  where  the  broom  must  be  used,  and 
the  only  kind  to  use  are  those  that  are  drawn  with  wire,  because  the  cotton-  or 
hemp-twine  drawings  will  soon  rot  and  the  broom  will  fall  to  pieces.  Wire-drawn 
brooms  cost  more  than  the  others,  but  they  will  last  more  than  twice  as  long. 
Cheap  corn  brooms  are  the  dearest  that  can  be  bought.  The  best  substitute 
for  the  corn  broom  is  the  mule-hair,  double  length,  wire-drawn  brush,  and  the 
larger  the  size  the  better  the  service.  The  brushes  need  to  be  washed  frequently 
in  tepid  or  cold  water;  when  the  bristle  is  laid  in  pitch,  as  is  a  common  practice 
with  makers,  hot  water  will  soften  the  pitch  and  break  up  the  brush.  These 
mule-hair  brushes  cost  from  $1.50  to  $3  each,  but  they  will  last  for  years  with  care- 


PURCHASE    OF    SUPPLIES  579 

ful  using.  On  all  floor  brushes  there  should  be  a  felt  binding,  so  that  the  hard  edge 
of  the  wood  part  of  the  brush  will  not  knock  the  paint  off  the  walls  and  varnish 
off  the  furniture. 

One  of  the  most  useful  brushes  in  an  institution  is  the  radiator  brush,  intended 
to  reach  between  the  coils  of  the  radiator,  and  a  very  special  brush  is  required  for 
this  purpose.  The  sanitary  hopper  and  toilet-bowl  brush,  the  radiator  brush, 
the  bed-pan  and  urinal  brush  should  be  all  wire  drawn  and  fastened  on  a  metal 
handle,  preferably  heavy  tipped  wire.  Properly  made  brushes  of  this  sort  can  be 
cleaned  any  number  of  times,  and,  as  it  is  the  cleaning  process  that  wears  them 
out  and  not  the  actual  use,  they  should  be  made  so  that  they  will  stand  hot  and 
cold  water,  soapsuds,  and  disinfectants,  and  wooden  handles  will  not  stand  these 
things  nor  will  twine  binding. 

There  is  a  wall-cleaner  brush  that  is  very  excellent.  It  is  made  of  short  ostrich 
feathers,  and  seems  to  be  the  only  brush  that  can  be  used  to  pick  up  dust  and 
not  scatter  it.  It  can  be  cleansed  by  a  gentle  washing  in  lukewarm  water.  In 
some  places  they  use  this  brush  wet  for  washing  windows.  It  is  a  very  durable 
brush,  and  will  last  for  years  if  taken  care  of.  Where  there  is  much  floor  to  keep 
clean,  and  especially  where  the  floors  are  very  much  used  by  people  with  muddy 
shoes,  there  is  a  sort  of  scrubbing  brush  known  as  a  "deck  scrub."  It  is  about 
twice  the  size  of  the  regular  scrubbing  brush,  has  a  high,  heavy  wooden  back,  the 
whole  containing  a  long  handle.  Scrubbing  cannot  be  done  quite  as  well  on  the 
hands  and  knees  with  this  brush,  but  it  is  a  very  good  substitute  if  used  vigorously. 
The  difference  is  that  the  operator  can  use  it  without  getting  on  hands  and  knees. 


THE  HOUSEKEEPING  DEPARTMENT 

The  Housekeeper. — People  in  this  world  occupy  large  or  small  places,  not  be- 
cause of  the  largeness  or  smallness  of  the  places  themselves,  but  according  to  their 
ability  to  fill  them.  Nowhere  is  this  truer  than  in  the  personnel  of  the  housekeeper 
or  matron  in  an  institution  of  any  sort,  whether  it  be  a  hotel,  sanitarium,  or  hospital. 
We  may  employ  a  woman  as  matron  for  an  institution,  and  map  out  for  her  the 
duty  of  looking  after  the  female  help,  to  see  that  the  floors  and  rooms  are  kept 
clean.  There  are  women  wholly  incompetent  to  fill  even  so  limited  a  place  as  that, 
but  there  are  other  women  who  'will  do  the  work  assigned  to  them,  and  do  it  well, 
but  who  will  do  no  more  than  that,  and  in  such  a  position  will  have  reached  the 
height  of  their  capabilities. 

But  there  are  other  women,  and  we  all  know  such,  who  literally  take  possession 
of  the  housekeeping  atmosphere  about  them,  who  not  only  attend  to  their  own 
duties,  but  who  are  constantly  helping  out  on  something  else;  and  this  world  is  full 
of  work  for  people  who  are  looking  for  it;  busy  and  competent  women,  who  know  how 
to  manage  things  and  get  work  out  of  people  and  to  make  the  housekeeping  parts 
dovetail  each  into  the  other.  And  these  women  will  constantly  find  new  duties 
to  perform,  and  if  they  cannot  find  them  they  will  make  them,  until  the  whole 
establishment,  upon  its  domestic  side,  will  take  on  an  atmosphere  of  businesslike 
activity,  and  the  stamp  of  the  housekeeper  will  be  upon  it  all. 

In  attempting  to  define  the  duties  of  a  housekeeper,  therefore,  we  find  ourselves 
confronted  with  a  personality,  and  no  one  who  has  charge  of  the  administration  of 
any  sort  of  large  institution  could  write  about  the  domestic  side  of  it  without  a  pic- 
ture in  his  mind  of  some  individual,  and  his  story  of  housekeeping  would  be  an 
epitome  of  the  life-story  of  some  particular  woman. 

In  a  small  hospital  the  duties  of  the  matron  or  housekeeper  may  be  merged  with 
those  of  the  superintendent  of  the  training-school  and  the  superintendent  of  the 
hospital,  and  a  large  measure  of  the  success  of  such  an  institution  will  depend  on  the 
ability  of  the  woman  at  the  head  of  it,  not  as  a  nurse  or  superintendent,  but  as  a 
managing  housekeeper.  Of  course,  in  such  an  institution  the  woman  must  be  a 
many-sided  person,  and  the  broadness  of  her  success  will  be  measured  by  her 
abilities  in  many  directions;  as,  for  instance,  she  must  have  diplomacy  and  tact 
to  deal  with  the  public  and  with  the  medical  staff  and  with  the  interns.  And, 
in  order  to  deal  with  the  medical  staff  and  with  the  training-school,  she  must  have 
great  technical  ability  and  poise.  But  in  a  final  analysis  of  her  achievements  at 
the  head  of  the  institution  her  housekeeping  performances  will  shine  out  as  the 
thing  that  people  will  talk  about.  An  immaculate  establishment,  clean  linens  and 
a  well-disciplined  force  will  make  up,  in  the  eyes  of  the  directors  and  those  inter- 
ested in  the  institution,  for  many  a  shortcoming  elsewhere. 

It  has  been  said  frequently  by  those  who  ought  to  know  that  a  woman,  tem- 
peramentally, is  not  calculated  to  handle  subordinates;  that  she  is  likely  to  domineer 
and  dictate  to  a  point  that  men  will  not  work  for  her,  and  that  the  same  woman  is 
likely  to  be  so  unjust  to  her  female  help,  in  favoring  some  and  driving  others,  that 
no  proper  discipline  can  be  maintained  among  the  females  of  the  establishment. 

580 


THE    HOUSEKEEPING    DEPARTMENT  581 

The  experience  of  some  of  us,  however,  does  not  bear  out  any  such  presump- 
tion, and  we  would  prefer  to  fall  back  again  upon  the  personal  equation.  It  is  a 
case  df  the  woman  in  the  concrete  and  not  the  woman  in  the  abstract,  because  it  is 
the  woman  who  is  running  the  establishment  and  not  womankind  at  large. 

It  has  been  said  again  that  the  female  mind  is  not  of  a  mechanical  turn,  and 
(hat  a  housekeeper,  ever  so  good  in  other  particulars,  cannot  direct  affairs  in  an 
institution  that  has  to  do  with  the  mechanics  of  the  place — the  lighting,  heating, 
elevators,  dumb-waiters,  and  so  ad  infinitum.  It  is  probably  true  that  women  are 
not  mechanics,  and  that  they  are  not  of  a  mathematic  or  even  a  mechanical  turn 
of  mind.  But  there  are  some  women  who  can  get  more  good  work  out  of  a  plumber 
than  almost  any  man  by  the  force  of  their  personality,  coupled  with  a  few  kindly 
hints  of  a  very  commonplace  but  also  of  a  very  common-sense  character.  And  that 
holds  true  in  the  laundry  and  in  the  power  plant  and  everywhere  else  in  the  insti- 
tution. 

These  thoughts  would  seem  to  lead  up  to  the  fundamental  idea  that  a  house- 
keeper's duties  in  an  institution  are  just  what  she  is  capable  of  making  them,  and, 
while  there  may  be  many  objections  on  the  part  of  the  heads  of  other  departments 
in  an  institution  against  the  usurpation  of  their  powers,  privileges,  and  duties  by 
a  housekeeper,  we  will  rarely  find  this  to  be  the  case  where  there  is  a  commanding 
figure  in  that  position;  the  figure  of  a  woman,  so  busy  about  getting  things  done 
that  she  has  no  time  to  hear  complaints  about  her  activities,  and  who  is  even  too 
busy  to  see  sour  faces.  But  she  is  likely  to  see  all  the  loafers  on  the  place,  and  see 
them  when  they  least  expect  it.  And  such  a  housekeeper  as  we  have  been  pictur- 
ing is  very  likely  to  add  to  all  her  other  abilities  such  a  fine  intuition  that  she  can 
detect  a  loafer  even  in  his  busiest  moments. 

Every  one  of  us  can  recall  valuable  experiences  with  housekeepers.  We  can 
retrace  our  steps  in  hospital  administration,  and  look  back  upon  some  one  particu- 
lar occasion  when  a  housekeeper  was  employed  with  the  most  limited  duties,  and 
we  can  remember  how  we  were  freed  from  anxiety  about  a  lot  of  things  that  had 
bothered  us  before;  how  things  began  to  take  on  a  clean  and  tidy  look  and  a  business- 
like air.  And  about  all  we  can  remember  distinctly  of  that  period  is  the  fact  that 
Ave  seemed  to  meet  the  housekeeper  at  every  turn  of  a  corridor  and  on  every  floor 
of  the  house.  Presently  something  entirely  outside  of  her  duties  would  annoy  us, 
and  we  would  appeal  to  the  housekeeper,  and  immediately  that  particular  thing 
seemed  to  vanish  as  a  problem.  Then  something  else  would  transpire,  and  that, 
too,  would  he  smoothed  out  and  we  would  be  permitted  to  forget  it,  and  we  would 
wake  up  some  fine  morning,  making  a  mental  retrospect,  to  find  that  most  of  the 
establishment  had  been  taken  over  by  the  housekeeper,  and  that  no  matter  what 
was  wanted  she  had  to  be  appealed  to. 

It  can  hardly  lie  surprising,  therefore,  if  one  who  has  been  particularly  happy 
in  his  experience  with  housekeepers  should  set  out  upon  a  discussion  of  the  domestic 
side  of  institution  management  with  something  of  a  panegyric  upon  that  good  soul, 
the  housekeeper,  and  hardly  less  surprising  if  lie  should  take  her  as  a  foundation 
key  upon  which  to  build  a  fabric  of  domestic  tranquillity  and  efficiency. 

We  may  now  prOc 1  to  take  up  the  threads,  one  after  another,  of  the  domestic 

fabric,  and  think  about  them  from  the  mental  view-point  of  the  ellicicnt  house- 
keeper. 


582  OPERATION   OF   THE    HOSPITAL 

Feeding  the  Hospital 
operations  in  the  kitchen 

Good  housekeeping  starts  in  the  kitchen;  it  begins  with  a  clean  kitchen  and  it 
proceeds  with  clean  utensils,  clean  and  efficient  help,  with  properly  purchased,  prop- 
erly cooked,  and  properly  served  foods.  It  may  be  that  there  is  a  steward  in  the 
establishment  entirely  separate  from  and  independent  of  the  housekeeper,  but  it 
is  not  very  likely  that  a  steward  or  buyer  will  continue  for  very  long  to  furnish 
kitchen  commodities  that  an  efficient  housekeeper  has  occasion  to  find  fault  with, 
so  that,  even  where  the  establishment  is  so  large  as  to  afford  a  contract  buyer 
or  a  steward  or  both,  the  housekeeper,  when  the  last  word  is  said,  is  the  final  court 
to  determine  the  quality  and  economy  of  food  supplies. 

We  do  not  dwell  on  the  number  of  people  necessary  to  perform  the  work  in  the 
kitchen;  that  will  depend  wholly  upon  the  size  and  many-sidedness  of  the  insti- 
tution and  the  number  of  people  to  be  fed.  Therefore,  we  may  discuss  the  steps  of 
the  work  in  the  kitchen  instead. 

Let  us  take,  for  instance,  the  butcher  shop  and  the  presiding  genius  of  that 
establishment,  because  the  meats  are  perhaps  the  most  important  article  of  food — 
at  least  from  the  standpoint  of  institution  management.  The  butcher  may  have 
an  infinite  variety  of  other  duties  to  perform,  because  his  establishment  may  be 
very  small  and  his  duties  of  meat-cutting  light,  but,  whatever  else  he  may  have  to 
do,  no  particular  ability  that  he  may  possess  in  any  other  direction  will  pay  nearly 
so  well  as  his  ability  as  a  good  meat-cutter,  and  it  makes  no  difference  whether  a 
few  roasts  and  steaks  and  chops  and  boiling  joints  are  the  sum  total  of  the  day's 
meats,  or  whether  whole  carcasses  measure  the  demand,  there  is  more  in  cutting 
meat  properly  than  in  any  other  single  economy  in  the  house,  except,  perhaps,  the 
buying  of  meat  properly. 

In  a  good  many  institutions  that  are  well  conducted  only  one  quality  of  meat  is 
purchased,  and  that  in  carcass  size  and  of  the  very  best  quality,  short  of  what  are 
called  fancy  stocks.  When  the  butcher  comes  to  his  task  in  the  morning  he  has 
in  his  mental  vision  quite  a  few  classes  of  hospital  inmates  to  provide  for.  There 
are  the  nervous,  hard-to-please  private  patients,  never  hungry  at  best,  and  likely 
just  now,  since  they  are  in  the  hospital  for  some  real  or  fancied  illness,  to  be  harder 
than  ever  to  satisfy,  and  naturally  they  must  have  the  choicest  morsels — the 
tenderloins,  for  instance — because,  while  from  a  purely  physiologic  and  chemic 
standpoint  the  tenderloins  are  not  so  nutritious  as  some  other  parts  of  the  carcass, 
they  are  at  least  supposed  to  be  daintier  and  more  tender.  Then  there  are  the  con- 
valescents and  other  sick  people  who  need  the  most  nourishing  foods,  such  as  the 
sirloins,  and  the  ward  patients,  postoperative  surgical  cases,  perhaps,  who  need 
strong,  nourishing  meat  rather  than  the  tempting  tidbits,  and  without  particular 
reference  to  its  tenderness  so  long  as  the  chemic  strength  and  filling  power  are 
there.  Then  we  come  to  the  well  people  of  the  establishment;  the  guests'  dining 
room,  to  which  must  go  very  choice  viands,  because  the  people  who  eat  in  the  guests' 
dining-rooms  are  usually  the  friends  and  relatives  of  very  sick  patients,  and  they  are 
anxious  and  in  trouble  and  their  appetites  must  be  tempted;  so  they  must  have 
the  fancy  pieces,  daintily  served.  Then  we  come  to  the  hard-working,  robust  people 
of  both  sexes,  the  interns  and  nurses.  It  is  no  easy  task  choosing  quality  or  quantity 
or  variety  of  meats  for  these  young  people.  They  are  robust  and  hardy,  it  is  true, 
and  they  work  hard  and  should  have  good  appetites  for  any  plain,  wholesome  food, 
but,  as  a  matter  of  fact,  they  are  confined  a  good  deal  in  the  establishment,  do  not 
get  nearly  so  much  oxygen  into  their  systems  as  they  ought  to  have  because  con- 


THK   HOUSEKEEPING    DEPARTMENT  583 

fined  to  the  house  too  much,  so  their  metabolism  is  not  of  the  best  and  they  clog  up 
easily,  and  are  frequently  "off  their  feed,"  as  the  farmer  would  say  of  his  stock. 

Then,  last  of  all,  we  have  the  downstairs  help.  And  just  here  we  reach  a  sore 
spot  in  hospital  management,  not  only  concerning  meat,  but  in  all  the  other  table 
supplies.  A  good  many  of  us  "save  at  the  spigot  and  waste  at  the  bung"  about 
our  downstairs  help.  We  spend  all  we  dare  on  the  rest  of  the  house,  and  by  the 
time  we  get  to  the  downstairs  help  the  spirit  of  economy  has  firm  hold  of  us,  and 
it  is  a  question,  not  what  we  shall  feed  our  help,  but  how  poor  a  quality  may  we 
feed  them  and  how  small  a  quantity,  and  yet  keep  them  in  a  temper  to  remain  in 
the  service  with  sufficient  strength  to  perform  the  duties  for  which  they  are  paid. 
These  people  are  not  accustomed  to  the  choice  cuts  of  meat — they  never  had  them 
at  home — and  the  choice  cuts  are  by  no  means  the  most  nourishing  after  all. 
There  is  not  nearly  so  much  nourishment,  pound  for  pound,  in  a  tenderloin  steak 
as  there  is  in  a  round  steak  or  a  round  made  into  a  pot  roast.  But  boiled  meats 
lose  a  good  deal  of  their  nutritive  value  in  the  process  of  boiling,  and  yet  an  average 
floor  man  will  eat  four  or  five  times  more  in  weight  of  a  steak  than  he  will  eat  in  a 
roast.  It  is  no  exceptional  case  for  a  working  man  to  eat  a  pound  and  a  half  or  even 
two  pounds  of  steak  if  he  can  have  it ;  but,  if  the  meat  is  a  round  roast  or  a  pot  roast, 
and  if  it  be  served  with  good,  rich  gravy  and  plenty  of  potatoes,  well  cooked  and 
well  served,  one-sixth  or  one-eighth  of  a  pound  will  fulfil  every  gastronomic  pur- 
pose. Stews  of  various  sorts  may  be  frequently  served  to  the  help,  but  those 
people  are  entitled  to  have  their  stews  made  out  of  good,  clean,  fresh  meat,  and  it 
is  just  about  as  easy  to  make  a  good  stew  as  it  is  to  make  a  poor  one.  There  is  no 
more  attractive  or  appetizing  dish  than  a  properly  made  beef-stew,  with  a  little 
onion  and  red  pepper,  quartered  potatoes  or  dumplings,  not  with  milk-colored, 
dish-water  gravy,  but  the  rich,  brown  gravies  of  the  army  "mulligan." 

Then  we  have  the  ground  meats  that  can  be  prepared  and  served  in  an  infinite 
variety  of  ways.  Meat-balls,  as  they  are  served  in  many  institutions  to  the  com- 
mon help,  are  about  as  uninviting  a  dish  as  can  well  be  conceived;  as  a  rule,  they 
have  no  seasoning  and  are  fried  in  left-over  grease;  sometimes  they  are  cooked  so 
long  that  but  for  the  rancid  grease  they  would  have  about  as  much  taste  as  a  thor- 
oughly rotted  piece  of  drift-wood.  But  let  us  take  the  same  ground  meat,  add  to 
it  just  a  suspicion  of  garlic,  or,  far  better,  some  finely  chopped  onion;  take  about 
twice  as  much  finely  chopped  potatoes  as  there  is  of  meat;  bake  in  deep  pans  with 
a  bottom  crust  of  good  pastry  and  a  top  crust  of  the  same;  make  the  pie  of  such 
consistency  when  it  is  done  that  it  will  not  run  over  the  plate;  there  is  hardly  a 
nicer  dish,  even  for  the  rich  man's  table.  Sometimes  this  same  mixture  can  be 
made  in  little  individual  rolls,  using  a  good  pastry;  turn  in  a  sufficient  amount  of 
the  meat  and  potato  mixture  to  serve  one  individual;  and  precisely  the  same  mix- 
ture can  be  cooked  down  for  hash,  and  if  the  gravy  be  browned  it  makes  a  delicious 

dish. 

Now  let  us  go  along  with  the  help's  table  until  the  Sunday  dinner.  Chicken 
usually  costs  a  good  deal  of  money,  and  most  institutions  can  hardly  afford  to  serve 
chicken  to  the  common  help  as  a  regular  thing.  But  there  are  quite  as  many  econ- 
omies to  lie  practised  in  the  killing  and  preparing  and  serving  of  poultry  as  in  other 
kinds  of  meat,  and  it  may  be  safely  ventured  that  the  help  can  be  given  a  Sunday 
dinner  of  good,  healthy,  but  old  and  tough,  and  consequently  cheap  hens,  at  a  price 
that  will  compare  very  favorably  with  almost  any  other  meat  :  not  roast  or  fried  or 
boiled  chicken,  but  chicken  with  dumplings  or  frieasees,  with  plenty  oi  dumplings 
and  plenty  of  gravy,  and  for  a  change  they  may  have  what  the  French  call  "jam- 
bolia."    This  last  dish  i-  a  very  delicious  one;  the  fowl-,  are  disjointed — not  chopped 


,  584  OPERATION    OF   THE    HOSPITAL 

up  with  a  cleaver  and  their  bones  all  broken — and  cooked  until  the  pieces  just  hold 
together;  an  hour  before  they  are  done  a  few  onions  may  be  dropped  into  the  pot 
and  a  little  red  or  green  pepper  with  the  regular  seasoning  of  salt.  A  large  quantity 
of  broken  rice — broken,  because  that  is  the  cheapest  form  of  rice  and  quite  as  good 
as  the  whole  grains — should  have  been  soaking  in  cold  water  while  the  chicken  has 
been  cooking,  and  just  as  the  chicken  is  done  the  rice  may  be  dropped  into  the  pot. 
Then  another  half-hour  of  simmering,  and  the  rice  is  thoroughly  cooked,  and  the 
chicken  about  ready  to  fall  to  pieces. 

All  these  are  suggestions  to  help  out  the  butcher  in  his  oftentimes  difficult 
task  of  making  his  food  allowance  check  up  consistently  with  the  appetites  of  the 
people  he  must  feed. 

Preparation  of  Vegetables. — Some  day  some  enterprising  manufacturer  of  a 
vegetable-peeling  mechanism  will  give  us  some  exact  data  as  to  the  efficiency  of 
this  mechanism.  Up  to  the  present  time  we  can  only  speculate,  and  apparently 
there  has  been  no  attempt,  except  in  the  way  of  high-sounding  adjectives,  to  prove 
to'  us  that  there  is  a  real  saving  in  the  mechanical  peeling  of  potatoes,  turnips, 
carrots,  and  other  root  vegetables.  This  much  may  be  said,  every  mechanical 
device  for  peeling  these  roots  that  we  have  offered  to  us  to-day  gives  us  an  uncertain 
result.  They  do  not  peel  the  same  thickness  from  all  parts  of  the  outer  surface 
of  the  vegetable,  but  they  do  take  the  peel  off,  and  with  it  an  indefinite  amount  of 
the  very  best  part  of  the  vegetable.  There  are  two  parts  to  a  potato — the  inner 
part  that  is  almost  pure  starch,  and  a  thin  rind,  just  under  the  peel,  that  contains 
whatever  protein  is  in  the  potato.  It  may  be  urged  that  we  also  lose  this  protein 
value  in  the  peeling  of  the  potato  by  hand,  and  that  is  true,  but  what  we  want  in 
the  mechanical  potato  peeler  is  a  device  whereby  this  best  part  of  the  potato  can 
be  saved,  and  we  haven't  it  yet.  Moreover,  the  mechanical  potato  peelers  of  the 
day  do  not  take  out  the  eyes,  and  they  leave  the  peel  wherever  there  is  a  straight 
or  concave  surface,  and  only  perform  their  work  where  there  is  a  distinct  convexity. 
The  old-fashioned  hand-worked  apple  peeler  of  thirty  years  ago  was  a  far  more 
perfect  mechanical  device  than  anything  we  have  to-day  for  peeling  potatoes, 
because  it  did  follow  the  irregularities  of  the  surface,  and  it  may  be  very  pertinently 
inquired  whether  there  is  a  real  saving  of  time,  either  over  entire  hand  work  in 
potato  peeling  or  over  the  old-fashioned  apple  peeler,  because,  with  the  new  device, 
we  must  go  over  each  potato  by  hand  anyway  and  take  out  the  eyes,  the  straight 
or  concave  surfaces  that  have  not  been  peeled,  and  any  specks  that  may  exist. 
Almost  all  the  manufacturers  of  vegetable  peelers  show,  for  private  inspection  rather 
than  on  their  catalogues,  figures  to  prove  the  saving  in  weight  of  the  potato-machine 
peeler  as  compared  with  hand  work;  but  these  figures  contemplate  weighing  the 
potato  immediately  after  it  goes  through  the  mechanical  device  and  before  the  neces- 
sary amount  of  hand  work  is  done,  so  that  the  figures  are  not  entirely  disingenuous. 
However,  we  have  shown  in  the  section  on  Equipment  of  the  Institution  some  of 
the  best  forms  of  mechanical  vegetable  peelers,  and  have  pointed  out  somewhat 
the  difference  between  the  various  makes,  and  the  hospital  administrator  must,  at 
least  for  the  present,  be  the  best  judge  whether  the  conditions  surrounding  him 
would  seem  to  call  for  a  mechanical  device  rather  than  hand  peeling. 

There  is  very  little  to  be  said  about  the  advantages  or  disadvantages  of  mechan- 
ical against  hand  cleaning  of  most  other  vegetables.  Peas  must  be  shelled  by  hand 
as  of  old.  Strawberries  must  be  stemmed  in  the  old  way.  Lettuce  must  be 
washed  leaf  by  leaf.  The  cleaning  of  spinach  may  be  open  to  a  word  of  debate; 
most  of  us  are  familiar  with  home-cleaned  spinach,  especially  for  large  institutions, 
and  the  experience  is  not  a  pleasant  one.     Most  home-cleaned  spinach  retains 


THE   HOUSEKEEPING    DEPARTMENT  585 

much  grit,  and  for  institution  use  it  may  he  fairly  doubted  whether  canned  spinach 
is  not  more  desirable.  The  canners  of  that  commodity  seem  to  have  some  peculiar 
method  by  which  they  make  way  with  all  the  grit,  and  if  the  higher  priced  brands 
of  canned  spinach  are  purchased  there  is  always  a  debate  by  those  at  table  as  to 
whether  or  not  it  is  a  fresh  or  canned  vegetable,  and  agreement  will  only  be  reached 
on  the  one  point,  that  the  article  is  especially  free  from  grit,  and  there  are  some  of 
us  who  pretend  to  be  able  to  judge  by  that  fact  alone  whether  we  are  eating  canned 
or  fresh  spinach. 

Divisions  of  Table  Service. — It  is  an  arduous  and  thankless  job  for  the  house- 
keeper, dietitian,  or  chef  who  has  to  make  up  menus  for  the  various  classes  of 
institution  inmates  day  after  day,  and  it  must  often  be  done  without  much  refer- 
ence to  likes  and  dislikes,  and  sometimes  without  any  thought  of  the  availability 
of  the  food  as  actual  nutrition.  Perhaps  a  few  suggestions  may  be  grateful  to  the 
tired  one,  who  is  at  her  "wit's  end"  to  think  of  something  new  and  inviting  with 
which  to  meet  the  all  too  common  complaints  of  sameness. 

Digestion,  in  a  final  analysis,  is  a  process  of  oxidation.  The  concentrated  foods 
— that  is,  the  heavier  foods  and  those  containing  the  most  real  nourishment — 
require  most  oxygen  for  their  assimilation.  People  leading  active  out-of-door 
lives  are  abundantly  able  to  dispose  of  these  concentrated  foods,  such  as  meats, 
while  those  living  sedentary  and  indoor  lives  should  have  such  foods  in  much  smaller 
quantities.  Interns  and  nurses  are  active,  it  is  true,  but  their  lives  are  rather  irreg- 
ular, and  are  spent  in  sick  rooms,  with  comparatively  little  sunshine  and  fresh 
air;  such  habits  do  not  lend  themselves  to  food  oxidation;  therefore,  they  do  not 
need  a  great  amount  of  protein  food  in  concentrated  form,  though  what  food  they 
have  should  contain  plenty  of  nourishment,  and  in  a  form  that  will  call  into  activ- 
ity all  the  organs  of  digestion  and  elimination,  and  their  food  should  have  sufficient 
variety  and  attractiveness  to  excite  the  appetite,  however  tired  and  depressed  they 
may  be.  Carbohydrates,  and  the  foodstuffs  which  Hall  has  so  aptly  classified  as 
carbonitrogenous,  should  predominate  in  their  bills  of  fare.  Meat  and  eggs  once 
a  day  will  supply  the  body  needs,  if  vegetables  and  nuts  be  added  in  amounts  to 
suit  the  appetite.  Such  foods  as  these  will  furnish  the  bulk,  so  necessary  an  aid 
to  digestion,  as  well  as  the  protein,  and  may  be  served  in  such  a  variety  of  ways 
that  monotony  will  be  avoided.  The  nuts  will  add  to  the  supply  of  fat,  and  thus  in- 
crease the  energy-producing  fuel  and  at  as  small  an  expense  as  less  valuable  foods. 

Desserts  of  milk,  eggs,  and  fruit  can  be  put  together  in  such  an  infinite  number 
<if  ways  that  there  is  no  excuse  for  a  tiresome  "sameness."  Salads,  be  they  ever  so 
simple,  are  appetizing  if  only  for  the  bit  of  green  furnished,  and  may  produce  a 
desire  for  other  food — a  point  of  no  small  value  to  those  who  are  very  tired  or  for 
some  other  reason  do  not  care  to  eat. 

It  will  generally  be  found  that  nurses  and  interns  are  well  content  with  a  light 
breakfast.  The  expense  spared  here  can  be  added  to  the  other  meals,  or,  at  seasons 
of  the  year  when  fruit  is  more  expensive,  it  will  be  appreciated  if  tin-  is  served  even 
occasionally,  though  the  regular  breakfasts  are  more  simple.  All  things  considered, 
it  costs  no  more  to  serve  a  salad  or  fruit  than  it  does  to  serve  a  soup,  so  these  may 
bo  interchanged  or  alternated  for  dinner. 

As  to  the  downstairs  help,  they,  too,  must  have  nourishing  food,  and  it  must 
be  varied,  but  their  appetites  should  be  appeased  rather  than  excited,  and  they  are 
apt  to  scorn  the  so-called  dainties  as  not  worthy  of  being  called  food.  The  more 
nourishing  cuts  of  meat,  spaghetti,  macaroni,  beans,  puddings  of  cereals,  and  eggs 
are  all  suited  to  their  needs,  and,  if  properly  prepared,  will  be  found  most  satis- 
factory. 


586 


OPERATION    OF    THE    HOSPITAL 


Sample  Menus  for  the  Help 


Breakfast. 

Cereal. 

Mashed  potatoes.     Fried  eggs 

Bread.     Coffee  cake. 

Coffee. 

Dinner. 

Vegetable  soup. 

Chicken  with  noodles. 

Boiled  potatoes.     String  beans. 

Steamed  chocolate  pudding. 

Coffee. 

Supper. 

Cold  meat.     Baked  potatoes. 

Apple  sauce. 

Plain  cake. 

Breakfast. 

Cereal  with  milk. 

Fried  potatoes.   Liver  and  bacon. 

Bread.     Coffee. 

Dinner. 

Scotch  soup. 

Roast  beef.     Brown  gravy. 

Boiled  potatoes. 

Swiss  chard  (leaves). 

Pie. 

Supper. 

Boston  baked  beans. 

Stewed  tomatoes. 

Peach  tapioca. 

White  bread.     Rye  bread. 


Sunday. 

Notes  on  Sunday  Menu. 
Hens  may  be  bought  at  a  very  reasonable 
price,  and  if  cooked  below  boiling-point  can  be 
made  tender  and  of  good  flavor;  served  with 
noodles  or  dumplings  less  of  the  chicken  is 
needed,  and  yet  an  appetizing  serving  is  made. 
The  expense  is  warranted  by  the  satisfaction 
given  to  the  help  in  being  made  to  feel  that 
they  are  regarded  as  human.  There  is  no 
cheaper  or  better  dessert  made  than  steamed 
chocolate  pudding  as  well  as  some  other  steamed 
brown  puddings,  and  they  are  very  easily  made. 
The  supper  fits  in  nicely  with  the  other  menus. 


Monday. 

Notes  on  Monday  Menu. 
This  menu  fits  in  with  that  of  the  full  diets 
and  guests  very  nicely.  The  bacon  need  not 
be  of  as  good  cut,  and  the  fiver  will  reduce  the 
expense  of  the  breakfast  and  yet  not  reduce 
the  satisfying  property.  For  dinner,  the  better 
part  of  the  roast  may  be  served  upstairs  and  the 
remainder  downstairs;  in  the  same  way,  the 
stalks  of  the  Swiss  chard  to  the  guests  and  private 
patients  and  the  leaves  to  the  other  dining-room. 
The  same  dovetailing  may  be  followed  out  in 
the  supper  with  the  tomatoes  and  tapioca 


Tuesday-. 

Breakfast. 
Cereal  with  milk. 
Rice  cakes.     Baked  apple. 
Bread.     Coffee. 

Dinner. 

Rice  soup. 

Beef  steak  smothered  in  onions. 

Boiled  potatoes. 

Lemon  bread  pudding. 

Supper. 
Spaghetti  and  Tomatoes. 
Cheese.     Escalloped  potatoes. 
Peaches. 


Wednesday. 

Breakfast. 

Cereal  with  milk. 

Hamburg  steak.     Potatoes. 

Bread.     Coffee. 

Dinner. 

Turkish  soup. 

Veal  stew  with  dumplings. 

Potatoes.     Carrots. 

Bangor  pudding. 

Supper. 

Fried  sausages. 

Lyonnaise  potatoes. 

Plums. 

White  bread.     Brown  bread. 


Menus  for  Private  Patients  and  Guests 

Because  of  the  "servant  problem"  it  is  often  necessary  for  dinner  to  be  served 
at  midday.  Menus  arranged  judiciously  will  permit  the  same  things  to  be  served 
in  the  various  dining-rooms  the  same  day;  or  perhaps  the  left-over  meats  from  one 
day  can  be  served,  sliced  cold,  or  reheated  in  some  appetizing  combination,  the 
following  day;  the  unused  vegetables  can  be  served  en  casserole  to  the  help.     Meat 


TIIK    HOlSKKKKI'INCi    DKPAKTM  I  :\  1 


-)S7 


need  not  be  served  oftener  than  twice  a  day.     Very  little  so-called  heavy  salads  or 
puddings  should  be  served. 

Sunday. 

Notes  on  Sunday  M'  nu 
Plan  for  meals  which  are  easily  prepared,  as 
there  are  always  fewrer  maids  in  service  on 
Sunday.  Custom  has  established  the  idea  that 
Sunday  is  of  necessity  chicken  day.  Because 
chicken  for  dinner  is  prepared  on  Saturday,  it 
is  an  opportune  time  for  serving  the  livers  in 
bacon  for  breakfast,  which  is  known  as  "Pigs 
in  blankets."  This  utilizes  the  livers  in  a  way 
that  is  both  palatable  and  attractive,  and  makes 
a  pleasing  change  of  breakfast  meats  and  at  the 
same  time  economizes  by  using  something  inex- 
pensive. This  menu  requires  a  comparatively 
small  amount  of  work  in  preparation,  and  yet 
it  is  adequate  and  appropriate. 


Breakfast. 

Canteloupes. 

Cornflakes.     Farina. 

Pigs  in  Blankets. 

Toast.     Rolls. 

Tea.    Coffee.    Cocoa. 

Dinner. 

Tomato  bouillon. 

Celery. 

Roast  chicken  with  dressing. 

Jelly. 

Mashed  potatoes.     Asparagus. 

Pineapple  salad. 

Ice  cream. 

Tea.    Coffee.    Cocoa. 

Supper. 

Cold  roast  beef  and  ham. 

Baked  potatoes.     Sliced  cucumbers. 

Berries. 

Cake. 

Tea.    Coffee.    Cocoa. 


Breakfast. 

Plums  and  grapes. 

Toasted  rusks.     Wheatena. 

Bacon. 

Toast.     Rolls. 

Tea.    Coffee.    Cocoa. 

Dinner. 

Bouillon. 

Olives. 

Roast  beef.     Horseradish  sauce. 

Mashed  potatoes.     Swiss  chard  (stalks). 

Lettuce  salad. 

Snowball  pudding  (steamed). 

Tea.    Coffee.    Cocoa. 

Stipper. 

Cream  of  celery. 

Croutons. 

Potato  au  gratin.     Sliced  tomatoes. 

Tapioca  tutti  frutti. 

Coffee.      Tea.      Cocoa. 


Monday. 


Notes  on  Monday  Menu. 
Always  serve  a  clear  soup  with  a  heavy  meal; 
cream  soup  has  sufficient  food  value  to  be  a  main 
dish  at  luncheon  or  supper.  Roast  beef  will  be 
well  balanced  by  the  vegetable  and  salad  in 
this  case.  Horseradish  sauce,  made  with  whipped 
cream,  furnishes  the  needed  stimulus  for  a  slug- 
gish appetite;  cheese  with  the  potatoes  and  nuts 
with  the  tapioca  are  sufficient  protein  and  fat  for 
supper. 


Breakfast. 

Baked  apples. 

Puffed  rice.     Oatmeal. 

Soft-cooked  eggs 

Toast.     Rolls. 

Tea.    Coffee.    Cocoa. 

Dinm  r. 
Fruit  cocktail. 

Wafers. 
Braised  sweetbreads  with  mushrooms 

Mashed  potatoes,     French  peas. 

Peppers  stuffed  with  neufchatel. 

( 'harlot  t e  russe 

Tea.    Coffee.     Cocoa. 


Tuesday. 

Notes  on  Tuesday  Mi  nu. 

Sweetbreads    contain    nueleoprotein,    a    form 
richer  than  that  in  beef,  but  in  smaller  amounts. 

so  the  peaa  and  cheese  may  well  be  made  a  pan 

of  the  meal.    Chicken  and  spaghetti bination 

is  a  \  erv  good  way  to  utiliz ild  chicken,  as  well 

as  an  unusual  way  to  serve  a  thing  which  always 

stimulates  the  appetite. 

Suppt  r. 

t  Ihicken  tetrazzinni 

Gougecl  potatoes.      Celery  salad. 

Stewed  plums 
Cold  cakes. 
Tea.    Coffee     Co 


588 


OPERATION    OF   THE    HOSPITAL 


Wednesday. 


Breakfast. 

Shredded  wheat  biscuit  with  fruit. 

Broiled  ham. 

Toast.     Rolls. 

Coffee.    Tea.    Cocoa. 

Dinner. 

Consomme. 

Radishes. 

Roast  squab.     Jelly. 

Mashed  potatoes.     Cauliflower,  Hollandaise. 

Waldorf  salad. 

Sherbet.     Wafers. 

Tea.    Cocoa.    Coffee. 

Supper. 

Pea  puree. 

Toast  fingers. 

Potato  salad.     Cream  cheese. 

Blueberry  muffins. 

Jelly. 

Tea.     Cocoa.     Coffee. 


Notes  on  Wednesday  Menu. 


This  is  a  good  time  to  serve  a  little  more 
elaborate  menu.  As  the  salad  requires  con- 
siderable work,  the  dessert  should  call  for  very 
little.  The  supper  requires  a  great  deal  of  time, 
but  it  can  be  done  long  before  the  supper  hour. 


Thursday. 
Breakfast. 

Canteloupes. 

Puffed  rice.     Pettijohns. 

French  toast. 

Syrup. 

Rolls. 

Tea.     Coffee.     Cocoa. 


Dinner. 

Scotch  soup. 

Celery. 

Breast  of  veal,  stuffed  and  rolled. 

Mashed  potatoes.     String  beans. 

Endive  salad. 

Marshmallow  pudding. 

Tea.     Coffee.     Cocoa. 


Supper. 

Broiled  chops. 

Baked  potatoes. 

Floating  island  custard. 

Wafers. 
Tea.     Coffee.     Cocoa. 


Friday. 

Breakfast. 

Plums  and  grapes. 

Grapenuts.     Hominy  grits. 

Broiled  smelts. 

Toast.     Rolls. 

Tea.    Coffee.    Cocoa. 


Dinner. 

Clear  soup. 

_  Pickles. 

Baked  whitefish,  tartare  sauce. 

Mashed  potatoes.     Summer  squash. 

Macedoine  salad. 

Maple  mousse. 

Tea.     Coffee.     Cocoa. 


Supper. 

Spaghetti  a  la  Italienne. 

Creamed  potatoes.     Lettuce  nests. 

Baked  pears. 

Tea.     Coffee.     Cocoa. 

Friday  Notes. 

Here  again  the  salad  contains  a  large  per- 
centage of  protein  in  contrast  with  the  small  per- 
centage in  the  vegetables  served. 


THE  HOUSEKEEPING  DEPARTMENT 


:,n<i 


Saturday. 

Breakfast. 

Poaches. 

Malted  flakes.     Kalston's  food. 

Rice  croquettes.     Syrup. 

Toast.     Rolls. 
Tea.    Coffee.    Cocoa. 


Dinner. 

Creole  soup. 

Olives. 

Spring  lamb.     Currant  mint  sauce. 

Mashed  potatoes.     Carrots,  French  style. 

Cottage  cheese  salad. 

Gelatin  fruit  pudding. 

Tea.     Coffee.     Cocoa. 


Supper. 

Broiled  steak.     Baked  sweet  potatoes. 

Apple  fluff. 

Fruit  cookies. 

Tea.    Coffee.    Cocoa. 


FEEDING  THE  SMALL  HOSPITAL 

Small  hospitals  of  from  10  to  50  beds  are  springing  up  in  all  parts  of  the 
country,  largely  with  the  intent  to  supply  deficiencies  in  the  present  hospital 
facilities.  These  hospitals  are  built  and  intended  to  be  operated  by  one  or  a 
few  of  the  foremost  physicians  in  the  community.  We  have  considered  else- 
where the  necessary  equipment  for  such  an  institution.  Let  us  now  very  briefly 
go  into  the  question  of  feeding  such  a  small  hospital,  and  there  will  hardly  be  a 
more  profitable  method  of  doing  this  than  to  give  figures  of  amounts  of  food 
that  will  be  required.  These  figures  can  be  stated  in  tables,  and  will  perhaps, 
after  all,  be  more  expressive  than  any  amount  of  general  discussion. 

Table  No.  1  is  a  statement  of  the  ordinary  standard  fruits  and  vegetables 
required  by  the  same  hospital  for  one  week. 

Table  No.  2  (p.  590)  covers  the  question  of  the  meats  that  will  be  required 
for  a  50-bed  hospital  for  one  week  expressed  in  days  and  meals  and  pounds  of  meat. 


Canned  Fruits. 

2  dozen  peaches. 

2  dozen  pears. 

1  dozen  apricots. 

1  dozen  green  gage  plums. 

1  dozen  sliced  pineapples. 


TABLE   No.  1. 
For  One  Week. 

Vegetables  Canned. 

2  dozen  asparagus. 

9  gallon  cans  peas,  or 

3  gallon  cans  spinach  and  6  peas. 
3  gallon  cans  string  beans. 

3  gallon  cans  corn. 

3  gallon  cans  tomatoes. 


Dried  Fruits. 

30  pounds  prunes. 

20  pounds  dried  peaches. 

20  pounds  dried  pears. 


Frexh  Fruit  in  Season. 


1  barrel  apples. 

2  cases  oranges. 
1  case  lemons 

1  case  grapefruit. 

'J  cralcs  grapes. 
'_'  cases  peaches. 


1  case  apricots. 

1  bushel  pears. 

2  dozen  canteloupes. 

1  crate  pineapples. 

1  case  strawberries. 
1  case  cherries 
1  case  plums. 


8  bushels  potatoes. 

I  bushel  sweet  potatoes. 

I  sack  carrots. 

1  sack  onions. 

1  sack  beets. 


Staph  Goods 


1  barrel  cabbage. 
50  pounds  dried  beans 
65  dozen  eggs. 
70  pounds  butter. 


590 


OPERATION    OF    THE    HOSPITAL 


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THFO    HOUSEKEEPING    DEPARTMENT  591 


COST   OF  PRIVATE  VS.   CHARITY   PATIENTS 

The  question  is  often  asked,  and  never  answered:  "How  much  more  does  it 
cost  to  feed  a  private  patient  than  a  free  patient  in  the  hospital?" 

Any  answer  to  this  question  must  be  pure  speculation,  or  at  least  relative,  and 
based  upon  special  conditions  in  the  institution  involved.  It  is  no  answer  to  com- 
pare the  figures  of  cost  for  food  in  one  of  the  great  charity  hospitals  with  figures 
for  some  private  institution,  because,  in  the  one  case,  all  of  the  expense  will  be  based 
on  economy,  and  with  a  view  to  feeding  poor  people  who  are  not  accustomed  to 
luxuries — such  as  cheap  cooks,  cheap  service,  and  little  of  it — cheap  dishes,  and 
other  utensils,  and  cheap  help  of  all  kinds;  whereas  in  the  private  hospital,  the  high 
order  of  service  necessitates  the  employment  of  expensive  chefs  and  dietitians, 
and  expert  help  of  various  sorts,  such  as  coffee  and  tea  makers,  pastry  cooks,  expen- 
sive cutlery  and  dishes,  with  a  high  order  of  service  clear  up  to  and  including  the 
head  of  the  institution. 

In  mixed  hospitals  there  is  another  difficulty — a  part  of  the  soup  for  the  day 
will  be  fed  to  the  pauper  patient,  if  the  institution  is  run  upon  a  humanitarian  plane, 
and  part  of  it  will  go  to  the  private  patients.  Who  is  to  measure  the  exact  propor- 
tion that  each  gets?  The  best  cuts  of  the  roast  will  go  to  the  private  patients  and 
the  less  choice  to  the  free  wards.  Such  staples  as  potatoes,  rice,  butter,  eggs,  and 
milk  will  go  indifferently  to  the  private  and  free  patients.  Who  is  to  measure  the 
exact  amount  of  each  of  these  staples  the  two  classes  receive? 

In  other  words  we  can  only  generalize,  and  we  ought  to  set  out  upon  this  gener- 
alization with  some  fundamental  propositions:  first,  that  the  free  patient — who, 
by  the  way,  is  not  a  free  patient  at  all,  but  who  is  being  paid  for  by  some  generous 
man  or  woman  of  wealth — ought  to  have  just  as  pure,  wholesome,  and  nutritious 
food  as  the  private  patient  who  happens  to  be  paying  his  own  way,  and  that  the 
difference  in  the  food  of  the  two  is  only  in  the  matter  of  luxuries.  We  need  not 
give  to  the  free  patient  mushrooms,  brussels  sprouts,  and  asparagus  tips;  these 
are  merely  luxuries  demanded  by  the  rich,  who  would  be  much  better  off  without 
them.  Second,  the  quantity  and  kind  of  food  should  be  based  wholly  upon  the 
physical  condition  of  the  patient,  whether  he  be  a  rich  man  or  a  pauper,  and  not 
upon  any  financial  rating. 

If  we  assume  these  conditions — and  they  are  fair  propositions  in  this  day  of 
modern  philanthropy — then  we  have  only  one  other  comparative  factor,  and  that 
the  result  of  experiment.  A  rich  man  comes  to  the  hospital  io-day,  let  us  say,  and 
is  shown  to  a  private  room;  he  is  placed  upon  a  light  diet,  if  indeed  he  is  fed  at  all, 
and  is  prepared  for  an  operation  which  is  performed  two  days  later.  For  four  or 
five  days  this  patient  is  fed  on  a  liquid  diet — milk  and  a  little  broth;  presently  soft 
eggs  and  a  light  cereal.  In  the  course  of  a  week  he  is  beginning  to  take  substantial 
nourishment  and  is  perhaps  sitting  up.  In  the  meantime,  his  people  have  been 
coming  to  the  hospital  daily  or  oftener,  and  they  want  him  at  home;  and  as  he  is 
now  convalescent,  at  the  end  of.  say,  ten  days,  he  is  taken  in  an  automobile  or  even 
an  ambulance,  accompanied  by  a  trained  nurse,  to  a  luxurious  home,  where  all  of 
the  comforts  and  luxuries  can  be  purchased,  and  where  he  can  be  visited  as  frequently 
as  necessary  by  his  physician.  During  his  stay  in  the  hospital  lie  lias  had  a  special 
nurse,  so  (hat  the  hospital  has  not  been  compelled  to  furnish  the  floor  nurses  for 
him;  as  soon  as  he  arrived  at  a  period  of  convalescence,  where  he  could  partake  of 
expensive  foods  or  even  any  considerable  amount  of  any  sort  of  food,  he  is  taken 
home.  Then  another  patient  comes  to  that  room  for  ten  days  and  returns  home 
under  like  conditions;  then  perhaps  there  is  a  typhoid,  who,  as  soon  as  convales- 


592  OPERATION   OF  THE  HOSPITAL 

cence  is  far  enough  advanced  for  him  to  partake  of  substantial  food,  is  likewise 
taken  to  his  luxurious  home  for  convalescent  attention.  Such  a  private  room  as 
this,  changing  its  occupant  as  frequently  as  we  have  outlined,  will  take  care  of 
thirty  or  forty  patients  a  year  at  a  minimum  expense  to  the  institution.  The 
dressings,  if  there  have  been  any,  are  no  more  costly  than  those  for  the  pauper. 

Now  let  us  take  the  free  patient  or,  at  least,  a  bed  in  the  free  ward.  The  patient 
is  brought  to  the  hospital  as  in  the  former  case,  is  operated  upon,  and  gets  to  that 
stage  of  convalescence  where  he  begins  to  eat  substantial  foods.  He  cannot  be 
sent  home,  since  his  home  surroundings  are  unfavorable;  he  has  no  trained  nurse, 
and  his  attendants  are  members  of  his  ignorant  family  or  friends,  who  cannot  be 
trusted  to  see  that  he  obtains  the  proper  diet  or  the  proper  dressings,  so  he  must  be 
kept  at  the  institution  during  the  period  of  convalescence,  which  may  be  ten  days 
or  even  longer,  until  his  stay  has  lengthened  into  a  month,  and  for  a  large  part  of 
that  time  he  must  have  been  getting  nourishing  and,  consequently,  expensive 
foods. 

In  other  words,  the  bed  in  the  private  room  has  cost  comparatively  little,  be- 
cause each  of  its  occupants  has  gone  home  before  his  condition  permitted  him  to 
become  much  of  an  expense  in  the  matter  of  food.  On  the  other  hand,  the  occu- 
pants of  the  free  bed  have  been  on  full  diet  for  at  least  one-half,  and  oftentimes 
two-thirds,  of  their  stay  in  the  institution.  Reasoning  from  this  basis,  it  may  be 
fairly  doubted  whether  the  maintenance  of  a  bed  in  a  private  room  will  prove  more 
costly  than  one  in  the  free  part  of  the  hospital. 

EMPLOYMENT  OF  INSTITUTION  HELP 

Institution  help  is  a  problem  all  by  itself,  and  a  problem  that  will  perhaps  never 
be  settled.  It  is  a  constant  source  of  annoyance  and  oftentimes  of  despair.  Almost 
every  hospital  administrator  is  disposed  to  envy  almost  every  other  hospital 
administrator,  assuming  that  he,  and  he  alone,  has  this  great,  overpowering,  all- 
pervading  burden  concerning  help — the  inefficiency  of  help,  the  extraordinary 
demands  of  the  help,  the  dishonesty  of  the  help,  the  impossibility  of  maintain- 
ing a  discipline  among  the  help,  the  wastefulness  of  the  help;  but  it  would  seem 
that  we  are  all  sufferers  alike  in  this  regard,  and  the  signs  of  the  times  indicate 
that  the  difficulties  of  obtaining  proper  help  at  possible  prices  are  to  grow  greater 
rather  than  less,  because  hospital  wages  are  not  very  high,  and  the  wages  of  almost 
every  class  of  people  in  this  country  are  growing,  not  only  out  of  proportion  to 
the  service  contemplated,  but  out  of  proportion  to  the  value  of  the  help  we  finally 
obtain. 

But  this  problem  is  real,  and  it  is  one  that  we  must  meet  every  hour  of  the  day 
in  some  form  or  other,  and  to  that  end  we  must  fix  some  definite  policies  concern- 
ing the  employment  and  the  handling  of  help  that  will  promise  an  amelioration 
of  the  annoyances  and  embarrassment  in  proportion  as  we  systematize  our  work 
or  leave  it  in  an  unorganized  form. 

Asa  Bacon,  superintendent  of  the  Presbyterian  Hospital,  in  Chicago,  read  a 
very  excellent  paper  before  the  American  Hospital  Association  some  three  years 
ago  concerning  the  wages  of  hospital  help.  Mr.  Bacon  went  to  the  trouble  of 
securing  data  from  many  of  the  institutions  of  the  country,  and  his  figures  are 
of  immense  value,  not  so  much  on  account  of  the  exact  salaries  paid  for  the 
various  help  in  institutions,  because  those  salaries  change  from  year  to  year, 
but  as  showing  a  uniformity  in  the  wages  and  work  of  help  and  the  variations 
due  to  local  conditions  in  different  parts  of  the  country.     Mr.  Bacon's  figures 


THE    HOUSEKEEPING    DEPARTMENT  593 

are  rather  cold  facts  on  a  subject  that  resolves  itself  into  a  good  deal  of  senti- 
ment, and  one  that  is  tempered  in  a  very  large  measure  by  personal  equation, 
and  we  all  know  full  well  that  institutions  like  hospitals  in  this  country  have 
no  flat  rates  of  payment  for  employees  as  most  other  kinds  of  business  have,  for 
hospitals  are  not  unionized,  as  a  rule,  and  we  oftentimes  secure  the  services  of  a 
most  valuable  head  of  a  department  at  a  figure  ridiculously  low  from  the  stand- 
point of  the  actual  value  of  the  employee  to  the  institution.  As  for  instance,  a 
pharmacist  may  be  paid  $60  a  month  and  his  living,  and  he  will  be  of  so  mediocre 
a  caliber  that  we  will  be  compelled  to  go  into  the  market  and  buy,  at  practically 
prohibitive  prices,  things  that  a  more  efficient  man  would  make  out  of  crude  drugs, 
and  he  will  know  so  little  about  wholesale  prices  of  things  and  their  keeping  quality 
that  he  will  overbuy  of  perishable  things  and  underbuy  of  things  that  might  well 
be  purchased  in  wholesale  amounts  and  that  would  keep  until  used,  and  the  ser- 
vices of  such  an  indifferent  pharmacist  as  this  would  not  only  come  very  high  to 
the  institution,  but  in  reality  he  would  lose  and  waste  for  the  institution  very  much 
more  than  the  amount  that  would  secure  the  services  of  a  competent  employee;  so 
that,  while  the  institution  might  save  $10  or  $15  or  $25  a  month  on  the  services  of 
its  pharmacist,  it  would  waste  maybe  ten  times  the  amount  because  of  his  ignor- 
ance and  inefficiency.  And  this  same  thing  may  be  said  of  all  the  heads  of  depart- 
ments in  the  hospital. 

Trained  Help. — We  must  take  into  consideration  in  the  employment  of  help, 
especially  of  the  higher  order,  not  so  much  the  salary  that  we  must  pay,  but  the 
employee's  efficiency  and  ability  to  save  the  institution  money,  as  well  as  to  perform 
his  duties  in  a  competent  and  efficient  manner.  Very  often  in  looking  over  the 
financial  figures  of  an  institution  we  will  notice  that  the  salary  roll  is  high  and  the 
supply  purchases  very  low,  and  these  figures  have  an  immense  significance  to  those 
who  can  read  between  the  lines. 

There  is  no  set  rule  for  employing  the  higher  orders  of  help  in  an  institution. 
Once  setting  before  ourselves  the  duty  which  we  expect  the  employee  to  perform,  we 
must  look  for  the  man  or  woman  most  likely  to  perform  that  duty  in  an  efficient 
manner  and  then  pay  the  salary  asked. 

There  is  no  hard-and-fast  rule  by  which  we  can  find  the  help  that  we  need. 
There  is  no  source  of  supply  of  an  official  or  recognized  character.  We  must  find 
our  pharmacist  through  the  drug  channels  of  trade  and  through  the  drug  journals. 
We  must  find  our  engineer  through  the  unions  of  that  craft,  or  we  must  go  into  the 
plant  of  some  business  house  and  hire  an  engineer  over  their  heads,  if  we  can  find 
in  such  an  establishment  the  man  we  think  we  need. 

Storekeepers  are  born,  not  made,  and  some  institutions  must  search  continu- 
ously for  some  efficient  employee  to  have  care  of  the  stores  of  the  institution,  while 
another  hospital  may  be  so  fortunate  as  to  keep  one  faithful  employee  all  his  life. 

The  hospital  steward  is  a  creature  of  the  institution.  He  must  be  trained  for 
his  office,  and  his  training  must  be  had  under  tutelage  of  the  housekeeper,  the 
dietitian,  and  whoever  else  has  to  do  with  the  use  of  perishable  supplies  which 
are  within  the  realm  of  the  steward. 

There  are  no  hospital  dietitians  that  one  can  employ.  There  is  no  school  of 
dietetics  in  this  country  that  teaches  hospital  dietetics  worthy  (lie  name. 

The  head  of  the  milk  laboratory  is  preferably  a  trained  young  woman,  trained 
perhaps  in  the  institution  itself.  She  must  be  fairly  well  educated,  but,  above  all 
else,  she  must  be  conscientious  and  honest  in  her  work. 

The  department  of  hydrotherapy  will  usually  be  manned  by  Norwegian  or 
Swedish  masseurs  and  hydrotherapists,  because  the  schools  in  those  countries 
38 


594  OPERATION    OF    THE    HOSPITAL 

give  the  best  training,  and  the  men  and  women  trained  in  them  will  give  better 
satisfaction  than  any  others,  and  they  will  usually  be  faithful,  permanent,  and 
conscientious. 

We  have  said  elsewhere  what  we  thought  about  the  matron  and  her  assistants. 

Employment  of  Common  Help. — We  are  almost  reduced  to  the  necessity  to 
secure  our  common  help  from  among  recently  imported  foreigners,  especially  jani- 
tors, floor  men,  wall  washers,  garbage  carriers,  cleaners  of  various  sorts,  and  the 
maids.  American  men  and  women  do  not  take  kindly  to  menial  office,  and  perhaps 
they  would  not  do  the  work  so  well  if  they  did,  being  "above  the  job,"  so  to  speak, 
from  the  very  outset.  Germans,  Poles,  Hungarians,  and  Scandinavians  are  the 
commonest  available  hospital  help,  and  they  do  just  what  they  are  taught  to  do  and 
in  the  way  they  are  taught  to  do  it.  All  they  bring  with  them  to  a  situation  is 
their  honesty  or  dishonesty,  their  industry  or  slothfulness.  They  rarely  have 
any  capacity  for  technical  employment,  and  must  usually  learn  from  the  ground  up 
whatever  they  are  expected  to  know,  no  matter  how  many  positions  they  have  had 
or  how  long  they  have  been  in  the  country.  The  only  skill  that  these  people  seem 
to  have  as  an  inherent  asset  is  their  skill  in  pilfering,  and  that  skill  is  oftentimes  of 
so  crude  a  character  that  they  can  be  kept  from  practising  it  without  very  much 
difficulty.  But  nearly  all  these  people  have  attained  some  sort  of  reputation  for 
honesty  or  dishonesty  in  places  they  have  worked,  and  it  seems  that  employers 
of  help,  and  especially  employers  of  hospital  help,  are  growing  rather  more  particu- 
lar about  giving  certificates  of  character  and  credentials  of  ability  to  discharged  or 
leaving  employees  than  they  formerly  were.  It  is  rare  in  these  days  that  we  are 
deceived  by  employing  a  common  helper  who  has  come  with  references  from  some 
other  hospital,  and  usually  our  losses  in  the  way  of  petty  stealing  are  due  to  our 
own  carelessness  in  hiring  people  without  proper  recommendations.  It  is  not  often 
that  these  people  forge  credentials.  They  haven't  the  ability,  and  they  have  not 
a  sufficient  influence  with  a  hospital  administrator,  or  even  a  hospital  department 
where  they  have  worked,  to  secure  credentials  they  have  not  earned. 

When  the  housekeeper  or  the  head  of  any  other  department  of  a  hospital  hires 
a  new  employee  it  should  be  the  inflexible  rule  in  the  institution  that  the  employee 
shall  be  taken  to  the  business  office  of  the  institution,  and  put  through  the  regular 
technical  process  of  employment  before  he  or  she  is  permitted  to  go  to  work,  and 
this  procedure  should  be  taken  care  of  by  the  accountant  or  chief  clerk  of  the 
institution,  or  by  some  one  of  discretion  and  experience.  There  should  be  regular 
forms  for  employees  to  sign,  and  a  distinct  and  individual  account  ought  to  be  kept 
with  every  employee,  including  all  the  letters  of  recommendation  that  the  individual 
brought  with  him.  These  letters  of  recommendation  should  all  be  taken  up  when 
he  is  hired,  and  placed  in  the  file  pocket  with  the  official  papers  concerning  his 
employment.  A  definite  contract  should  be  signed  with  the  individual,  and  this 
contract  should  set  out  the  terms  of  his  employment. 

The  form  of  contract  should  specify  that  the  individual  is  employed  at  the 
pleasure  of  the  institution,  and  may  be  paid  off  at  any  time  "at  the  rate  of"  so  much 
per  month.  This  makes  it  possible  for  the  institution  to  discharge  an  employee  and 
pay  him  for  precisely  the  time  he  worked.  If  employees  are  hired  by  the  month, 
and  are  discharged  during  the  month,  the  labor  laws  in  most  parts  of  the  country 
will  compel  the  institution  to  pay  for  the  full  month,  and  it  is  easy  for  one  of  these 
employees  to  obtain  the  services  of  a  lawyer  either  to  compel  the  institution  to  pay 
or  to  make  a  good  deal  of  trouble. 

In  large  institutions  there  is  oftentimes  a  difficulty  in  keeping  outsiders  from 
obtaining  free  meals  in  the  institution,  and  to  this  end  some  institutions  have 


THE   HOUSEKEEPING    DEPARTMENT  595 

adopted  a  form  of  meal  ticket,  so  framed  that  the  ticket  can  be  punched  for  the 
three  meals  of  every  day  in  the  month,  ninety  meals,  and  this  ticket,  with  its 
appropriate  stub,  can  be  used  as  the  employment  card  of  the  employee.  This 
meal  ticket  is  of  some  importance,  and  we  produce  it  here: 


I    111222    3     3|3|4l4|4|5|5|5|6|6|6|7|7|7| 


I     8|9|9|9|l0|l0|10|n|ll|ll|l2|l2|l2|l3|l3|l3|l4|l4|l4|l5|l5|l5|l6 

No Date ', 

;        No.  Month. 

Name  Michael  Reese  Hospital 

EMPLOYEES'  MEAL  TICKET 
Department i 

|     Name 

!  SUPT. 

•  18|l6|l7|l7|l7|l8|l8|l8|l9|l9|l9|20|ao|20|2l|21  1 21 1 22 !  22 1 22 1 23 1 23 1 23 


24 1 24 1 24  25 1 25  25  26  26  2B  J  27  J  27  27  28  28 1 28 1 29 1 29 1 29 1 30 1 30 1 30 1 31 1 31 


Its  use  contemplates  the  stationing  of  some  trusted  employee  at  the  door  of  the  helps' 
dining-room  for  the  meal  hours,  and  the  ticket  of  each  employee  is  punched  as  he 
enters  the  room. 

In  the  card  file  of  employees,  which  contemplates  a  pocket  for  every  employee 
in  the  institution,  there  should  be  a  card  containing  all  the  necessary  information 
about  the  employee  in  addition  to  his  letters  of  recommendation.  This  card  will 
contain  the  name  and  age,  nativity,  length  of  time  in  this  country,  previous  places 
of  occupation,  with  details  as  to  time  employed,  his  present  address,  or  that  of 
parents  or  nearest  of  kin.  This  card  should  also  contain  information  about  the 
skill  of  the  employee  in  various  directions,  as  given  by  himself  at  the  time  of  employ- 
ment, setting  out  his  ability  to  do  certain  work,  the  time  that  he  served  in  such  work, 
and  the  like;  and  if,  after  the  employment  of  the  person,  the  institution  will  make 
inquiry  of  a  sufficient  number  of  the  people  named  as  reference  or  former  employers, 
to  give  a  fair  indication  of  the  truth  or  falsity  of  the  employee's  statements,  the 
institution  will  be  more  than  repaid  in  the  long  run,  because  there  is  no  question 
that  there  are  people  about  the  country  who  hire  themselves  out  not  for  the  pur- 
pose of  the  labor  they  intend  to  perform  and  the  wages  that  go  with  it,  but  with  a 
view  to  the  opportunities  for  theft,  and  the  freedom  of  movement  about  a  hospital 
gives  a  fair  field  to  any  employee  who  is  intelligent  enough  to  distinguish  the  valu- 
able things,  such  as  apparatus,  surgical  instruments,  microscopes,  and  the  like. 

If  the  employee,  when  he  is  hired,  is  to  have  a  uniform  or  keys  or  other  property 
of  the  institution  he  ought  to  be  compelled  to  sign  for  it. 

When  an  employee  is  discharged,  or  leaves  of  his  own  accord,  he  must  go  to  the 
business  office  of  the  institution  to  settle  his  affairs.  Oftentimes  employees  leave 
of  their  own  accord,  and  without  notice,  immediately  after  pay  day,  and  fchey  some- 
times embarrass  the  institution  by  their  non-appearance  the  next  day.  This  ran 
nearly  always  be  obviated  if  the  hospital  has  possession  of  the  employee's  letters  of 
recommendation.  Sometimes  an  employee  merely  gets  drunk  on  the  night  of  pay 
day,  and  after  sobering  up  a  day  or  two  later  is  ashamed  to  return.     He  may  have 


596  OPERATION    OF   THE    HOSPITAL 

been  an  excellent  man,  and  one  does  not  look  for  all  the  virtues  in  a  hospital  helper 
at  $20  per  month,  and  some  of  us  forgive  pecadillos  of  this  sort  as  being  one  of  the 
reasons  why  we  can  secure  the  services  of  such  a  man  at  so  low  a  price,  but  the 
employee  happens  not  to  know  this  policy.  However,  if  the  hospital  has  his  papers 
he  is  more  than  likely  to  return  for  them,  and  perhaps  to  go  back  to  work  again 
with  a  better  understanding  of  things. 

Most  well-conducted  institutions  make  it  a  rule  never  to  give  a  letter  of  recom- 
mendation to  a  discharged  employee,  or,  if  the  employee  has  been  discharged  for 
some  reason  other  than  his  own  deficiency  or  his  own  dishonesty  or  laziness,  and  the 
administrator  of  the  institution  feels  that  he  is  entitled  to  a  limited  recommenda- 
tion, the  facts  concerning  the  discharge  ought  to  be  set  out  so  that  a  future  employer 
will  have  the  advantage  of  whatever  information  there  was,  either  for  or  against 
the  employee.  Naturally,  if  such  a  letter  of  recommendation  is  a  handicap  to  em- 
ployment it  will  not  be  used,  and  will,  therefore,  do  no  harm. 

CLEANING  THE  HOSPITAL 

The  question  of  how  the  cleaning  of  the  institution  is  to  be  performed,  and 
whether  male  or  female  common  help  shall  be  employed,  is  one  that  settles  itself 
in  most  institutions.  Without  any  doubt,  the  fewer  men  we  have  the  less  trouble 
we  will  court.  Male  help  of  a  character  that  will  consent  to  scrub  and  mop  the 
place  is  about  the  lowest  possible  order  of  employees.  Such  men  are  almost  uniformly 
time  servers,  whose  chief  object  is  to  do  as  little  as  possible  for  the  money  they 
receive.  Some  of  them  are  more  alert  and  of  greater  intelligence  than  others,  and 
some  hospital  administrators  of  great  experience  in  the  handling  of  help  are  almost 
tempted  to  discharge  a  man  without  any  other  reason  than  that  he  has  displayed 
more  intelligence  and  alertness  than  befits  his  station;  the  philosophy  behind 
the  discharge  of  such  a  man  is  that  one  of  his  capacity,  willing  to  do  such  menial 
and  poorly  paid  work,  must  have  some  ulterior  motive,  and  hence  is  not  safe. 

There  are  many  large  and  well-conducted  institutions  in  which  men  have  been 
superseded  by  women  for  cleaning  service.  It  is  supposed  they  clean  better  and 
more  conscientiously  and  they  will  work  cheaper.  In  some  hospitals  the  cleaning 
work  is  apportioned  out  by  localities,  and  one  man  or  woman  is  detailed  to  keep  his 
or  her  locality  clean  all  the  time.  Elsewhere  the  housekeeper  or  an  assistant  heads 
a  gang  that  goes  over  the  house  from  garret  to  basement,  working  in  squads. 
This  system  has  the  advantage  of  a  guiding  and  directing  head  even  in  the  details 
of  the  work;  it  has  one  disadvantage,  namely,  that  some  parts  of  the  house  need 
much  more  attention  and  more  frequent  cleaning  than  others,  and,  where  a  sys- 
tematic covering  of  all  parts  is  done  in  rotation,  this  is  not  usually  feasible,  though 
in  some  hospitals  where  this  system  is  employed  a  few  of  the  worst  places  are  regu- 
larly cleaned  much  oftener  than  the  house  generally,  that  is,  the  routine  is  broken 
into  in  the  case  of  especially  dirty  places. 

There  is  another  question  that  frequently  comes  up,  especially  in  the  smaller 
hospitals,  namely,  how  much  of  the  cleaning  should  be  done  by  pupil  nurses  and 
by  graduate  specials  on  service  in  the  hospital. 

We  may  dismiss  the  thought  that  these  young  women  are  not  menials  with  the 
mere  suggestion  that  their  high  ideals  of  their  profession  are  not  likely  to  be  greatly 
encouraged  if  they  are  compelled  to  scrub  the  floors  and  sweep.  From  the  purely 
material  standpoint  of  dollars  and  cents,  leaving  out  every  sentimental  considera- 
tion, there  is  nothing  to  be  gained  by  making  pupil  nurses  do  the  cleaning.  It 
has  been  argued  that  the  pupil  nurses  are  paid  no  wages,  while  workwomen  are  paid, 


THE    HOUSEKEEPING    DEPARTMENT  597 

therefore  the  work  may  be  more  cheaply  done  by  the  nurses.  This  is  not  true;  in 
nearly  every  hospital  a  certain  percentage  of  the  pupil  nurses  are  employed  as 
"house  specials,"  for  which  service  the  institution  is  paid  $15  per  week,  or  $60  per 
month;  for  that  much  money  three  workwomen  may  be  hired,  any  one  of  whom 
is  capable  of  turning  out  a  greater  amount  of  menial  work  than  the  nurse  whose 
earnings  for  the  hospital  are  making  possible  their  employment.  Therefore,  the 
menial  work  should  all  be  done  by  strong  workwomen,  incapable  of  performing 
any  sort  of  technical  service,  even  to  the  cleaning  of  the  rooms  occupied  by  the 
patients  under  the  care  of  these  "house  specials."  It  goes  without  saying  that  the 
nurse  should  consider  it  a  part  of  her  duty  to  keep  her  patient's  room  tidy  and  neat 
once  it  is  cleaned  for  the  day. 


THE  INSTITUTION  LAUNDRY 

Just  why  the  laundry  should  be  allowed  to  persist  as  the  most  perplexing  and 
hopeless  problem  of  institution  management  is  not  quite  clear.  Perhaps  it  is 
because  there  are  no  laundry  consulting  engineers,  as  there  are  steam  and  electric 
and  various  other  mechanical  experts,  and  we  are,  therefore,  obliged  to  be  guided 
by  the  laundry  machinery  makers  or  a  not  always  very  practical  or  well-informed 
class  of  laundry  workers,  the  one  avowedly  interested  in  selling  machinery  and  the 
other  too  often  ignorant  of  the  more  abstruse  rules  of  cause  and  effect  about  their 
work. 

It  is  very  certain  that  architects  know  very  little  about  the  laundry  business 
or  its  requirements ;  their  engineer  collaborators  usually  know  very  little  more,  and 
the  hospital  manager  himself  has  not  a  sufficient  amount  of  exact  knowledge  to 
impress  his  views  upon  anyone  interested  in  the  building  and  equipment  of  the  new 
institution,  if,  indeed,  he  has  any  well-defined  views  to  advance.  The  result  is 
that  almost  everybody  concerned  is  agreed  that  the  laundry  is  not  a  very  attractive 
place,  and  that  it  ought,  therefore,  to  be  removed  as  far  as  possible  from  view. 
Who  ever  heard  of  an  architect  making  a  feature  of  the  laundry  in  his  plans  for  a 
new  institution,  or  who  ever  knew  of  a  board  of  directors  to  call  his  attention  to  the 
minor  place  to  which  that  part  of  the  institution  was  relegated?  And  thus  it  comes 
about  that  any  dark  and  well-hidden  hole,  not  otherwise  available,  is  designated  in 
the  plans  as  the  laundry,  and  the  laundry  machinery  people  are  commanded  to 
make  their  specifications  to  utilize  that  hole;  then,  when  the  figures  look  large,  the 
board  of  directors  will  be  startled  by  a  proposition  to  spend  so  much  money  in  such 
an  out-of-the-way  and  inconspicuous  place.  By  such  logically  sequential  stages  it 
transpires  that  the  institution  laundry  is  too  small  to  do  the  work,  that  the  quarters 
are  so  constricted  the  operators  cannot  work,  and  that  the  sanitation,  ventilation, 
and  surroundings  are  so  uninviting  no  self-respecting  people  will  remain  there. 
Therefore,  to  get  the  best  advice  on  the  laundry  subject  it  is  advisable  that  the 
laundry  be  one  of  the  early  considerations;  that  the  space  it  shall  occupy  shall  be 
alloted  early,  and,  to  best  decide  on  what  shall  be  the  requirements,  it  is  best  that 
a  consultation  be  had  between  the  interested  directors,  the  architect,  and  representa- 
tives of  the  leading  laundry  machinery  manufacturers.  This  conference  should 
be  held  with  all  representatives  present,  and  it  would  be  found  that  the  advice 
received  at  that  time  by  a  discriminating  board  would  not  be  governed  by  the  sole 
object  of  selling  machines,  but  advice  that  would  give  the  best  information  possible 
to  receive. 

Let  us  see  just  what  the  laundry  means  to  the  institution,  without  taking  any 
account  whatever  of  the  esthetic  side  that  contemplates  clean  and  dainty  bedcloth- 
ing,  neat,  comfortable  looking  patients,  and  tidy  interns,  nurses,  and  orderlies. 
According  to  a  very  conservative  calculation,  upon  which  we  shall  dwell  more  at 
length  hereafter,  the  average  linen  supply  per  patient  will  be  as  follows,  with  its 
approximate  cost  in  an  acute  disease  general  hospital  having  medical,  surgical,  ob- 
stetric, children's,  and  private  room  departments: 

598 


THK    INSTITUTION'    LAUNDRY  599 

20  sheets  at  S6  per  dozen $10.00 

3  spreads  at  SI  each 3.00 

20  cases  at  §2  per  dozen 3.33 

4  gowns  at  2.5  cents  each 1 .00 

20  face  towels  at  S2  per  dozen 3.33 

4  bath  towels  at  25  cents  each 1.00 

71  pieces $21.66 

This  means  that  each  bed  must  be  allowed  at  least  $20  worth  of  linen,  without 
counting  upon  any  reserve  stock,  and  at  least  two  pairs  of  blankets,  worth,  roughly, 
$6,  or  a  total  of  $26  worth  of  bed  furnishings.  In  a  hospital  of  100  patients  the 
total  value  of  the  linen  in  constant  circulation  would  be  $2600.  Now  add,  for 
purely  speculative  purposes,  the  clothing  and  bedclothing  of  executive  officers, 
interns,  nurses,  and  whatever  help  there  is  to  lodge,  and  we  have  some  idea  of 
the  value  of  the  goods  that  must  go  through  the  laundry  each  week. 

In  the  laundry  operated  upon  the  highest  plane  of  economy  consistent  with 
efficiency  these  goods  will  last  an  average  of  one  year.  It  is  not  the  use  of  goods 
that  wears  them  out,  but  their  abuse  in  the  laundry,  and  if  the  work  is  indifferently 
done  by  incompetent  and  careless  people  the  goods  will  not  last  more  than  half  so 
long;  there  will  be  an  expense,  therefore,  of  an  entire  new  supply  every  half-year. 
These  figures  can  only  be  given  in  the  rough  and  in  a  wholly  speculative  way,  but 
the  point  is  sufficiently  made  to  indicate  the  difference  between  a  good  laundry,  well 
operated,  and  a  poor  one. 

Laundry  Problems. — Aside  from  the  general  problem  of  the  laundry  and  its 
many-sided  phases,  not  capable  of  specific  reckoning,  there  are  a  few  questions  that 
present  themselves  definitely,  and  we  may  discuss  them  briefly  in  some  order: 

(1)  Is  the  laundry  work  more  advantageously  performed  in  and  by  the  institu- 
tion itself,  or  can  it  be  better  done  by  outside  parties  regularly  operating  the 
laundry  business? 

(2)  Wherein  does  the  hospital  laundry  differ  from  other  laundries  that  it  need 
be  considered  from  different  aspects? 

(3)  If  it  is  agreed  that  the  institution  shall  do  its  own  laundry  work,  what  capac- 
ity and  character  of  machinery  is  required  to  perform  a  given  amount  of  service? 

(4)  What  is  the  technic  of  the  institution  laundry  for  various  kinds  of  fabrics 
and  garments? 

(5)  How  shall  the  laundry  goods  be  handled  into  and  out  of  the  laundry,  checked, 
and  distributed? 

Home  or  Commercial  Laundry. — The  question  of  whether  we  shall  do  our  own 
laundry  work  in  the  institution,  or  send  it  out  to  a  concern  that  makes  a  business 
of  doing  laundry  work,  is  not  new.  Some  hospitals  are  to-day  having  their  laundry 
work  done  outside  the  institution.  The  cost  of  the  two  methods  is  about  the  same 
in  both  places,  and,  barring  a  favorable  or  unfavorable  condition  here  or  there,  the 
cost  may  be  flatly  stated  as  1  cent  per  piece  for  purposes  of  discussion,  whether  it 
be  clone  at  home  or  abroad. 

If  the  laundry  is  sent  out,  we  avoid  the  necessity  to  have  additional  rough  and 
undesirable  people  about  the  premises  who  are  difficult  to  handle.  It  is  always 
hard  and  oftentimes  impossible  to  obtain  the  services  of  a  competent,  sober,  and 
tractable  head  laundryman;  the  machinery  of  the  laundry  is  complex  and  needs  a 
great  deal  of  attention,  especially  in  the  hands  of  more  or  less  careless  and  inefficient 
people;  the  wear  and  tear  on  the  machinery  is  very  great  in  the  hands  of  a  force 
of  this  sort,  and,  unless  there  is  constant  watchfulness  on  the  part  of  some  one  in 
authority,  the  wash  work  will  be  indifferently  done,  many  articles  are  likely  to  be 


600  OPERATION    OF    THE    HOSPITAL 

stolen,  many  torn  and  otherwise  destroyed,  the  bleaching  processes  will  often  be 
overdone,  and  there  will  always  be  discomfort  and  annoyance.  It  is  well  to  remem- 
ber here,  however,  that  it  will  be  money  well  invested  to  engage  the  services  of  a 
competent  head  laundryman,  paying  him  for  the  service  on  an  equal  basis  of  what 
he  could  obtain  holding  a  similar  position  in  a  commercial  laundry.  With  a  good 
head  to  the  department,  the  troubles  of  the  balance  of  the  department  will  be 
greatly  reduced. 

It  may  be  well  questioned  whether  the  fabrics  will  be  better  cared  for  in  the 
commercial  laundry  than  at  home.  There  will  occasionally  be  a  better  accounting 
and  fewer  pieces  will  be  lost  in  the  commercial  laundry,  because  very  much  more 
care  will  be  taken  in  the  counting  at  home,  but  commercial  laundrymen  are  shrewd 
people  at  their  business,  and  they  are  disposed  to  wash  goods  at  the  least  possible 
cost  of  labor  and  material,  and  their  efforts  to  obtain  a  good  appearance  in  this 
product  often  leads  them  to  extremes  in  the  use  of  bleaches  and  starches.  One 
can  never  be  sure  of  sterilization  in  a  commercial  laundry,  hence  there  is  some  dan- 
ger in  the  use  of  the  articles  that  have  been  used  in  the  infectious  parts  of  the 
institution  and  that  may  have  escaped  the  disinfecting  processes  before  going  to  the 
laundry.  The  laundry  process,  however,  whether  home  or  at  commercial  laundries, 
requires  the  boiling  of  clothes  to  thoroughly  cleanse  them,  and,  even  if  bacteria 
should  remain  after  the  washing  process,  the  drying  and  ironing  under  high  tempera- 
ture would  almost  assure  perfect  sterilization.  The  commercial  laundry  is  usually 
at  some  distance  from  the  institution,  and  quick  returns  cannot  always  be  had. 

So  that  balancing  up  the  matter  from  every  view-point  there  is  hardly  a  ques- 
tion that  the  advantages  lie  largely  on  the  side  of  the  home  laundry,  for  at  home 
there  is  a  better  control  even  at  the  expense  of  annoyance  and  sustained  effort,  and, 
as  we  shall  see  hereafter,  perhaps  we  have  not  come  to  an  era  of  efficiency  in  our 
home  laundries  that,  if  practised  in  architecture,  equipment,  and  operation,  would 
very  much  more  than  settle  the  question. 

Some  good  hospital  managers  will  not  concede  the  advantages  of  the  home 
laundry.  The  Toronto  General  Hospital  has  been  happily  situated,  for  instance, 
in  having  at  convenient  distance  a  reformatory  for  females,  with  which  it  has  been 
able  to  make  laundry  arrangements  to  supplant  an  unsatisfactory  and  too  costly 
service  with  a  commercial  laundry.  In  their  new  hospital,  however,  a  home  laundry 
of  modern  equipment  is  contemplated.  Dr.  Henry  M.  Hurd,  of  Johns  Hopkins, 
finds  little  to  choose  between  the  two  methods,  excepting  on  the  score  of  the  better 
control  at  home.  E.  W.  Morris,  of  London,  in  a  recent  prize  essay  on  hospital 
economies  and  practices,  doubts  any  economy  or  advantage  in  the  home  laundry, 
but  suggests  a  "moderate  provision  for  badly  soiled  linen." 

Character  of  the  Hospital  Laundry. — The  hospital  laundry  is  made  up  of  an 
infinite  number  of  articles  covered  under  a  great  many  heads,  coming  from  a  great 
many  places,  after  having  been  used  in  vastly  different  ways,  and  soiled  all  the  way 
from  a  mere  wrinkling  to  stainings  and  acid  burnings  that  can  never  be  removed, 
excepting  with  the  knife  or  scissors.  The  hotel  laundry  is  vastly  simpler,  the  units 
of  the  wash  being  limited  there  to  the  bedclothing  and  table-cloths — that  is  sheets, 
spreads,  and  pillow  cases,  and  table-cloths,  towels,  and  napkins — and  the  same  may 
be  said  in  a  lesser  degree  of  the  sanitarium  and  sjDecial  hospital  in  which  only  one 
or  two  classes  of  patients  are  received. 

In  the  general  hospital  there  are  the  various  departments,  medical  and  surgical, 
free,  part  pay,  and  private  accommodations,  and  the  well  people,  interns,  nurses, 
and  administrative  officers,  and  the  help,  and  all  this  must  be  again  subdivided  into 
bedclothing,  table   clothing,  room   clothing,  such   as   curtains  and  dresser  tops, 


THE    INSTITUTION    L.U'NDKY  60] 

couch  covers,  and  screen  cloths,  and  all  this  must  again  be  divided  in  the  laundry. 
according  to  the  processes  involved  in  washing  the  different  fabrics  and  garments,  so 
that  there  is  infinite  detail  and  a  vast  division  in  the  hospital  laundry. 

Capacity  of  the  Laundry. — We  are  now  approaching  a  phase  of  the  laundry  prob- 
lem thai  is  the  subject  of  more  difference  of  opinion  between  hospital  administra- 
tors than  almost  any  other  question  that  pertains  to  institution  management,  and 
one  in  which  by  reason  of  the  difficulties  surrounding  definite  calculations,  one  may 
obtain  almost  any  figures  of  capacity  and  cost.  It  is  not  the  purpose  of  this  book 
to  quote  from  the  literature  in  any  direction,  but  to  give,  so  far  as  may  be,  the  con- 
sensus of  opinion,  based  on  the  expressions  of  competent  writers  and,  in  the  last 
analysis,  the  experience  and  judgment  of  the  author. 

Other  things  being  equal,  the  capacity  of  the  laundry  will  depend  on  the  char- 
acter of  the  institution.  First,  the  kind  of  patients  taken  care  of,  whether  they  be 
patients  likely  to  use  a  great  deal  of  laundry  goods,  such  as  the  children's  depart- 
ment, maternity  department,  and  the  surgical  sections;  and  quite  as  much  will 
depend  on  the  intent  of  the  institution  as  to  cleanliness  and  care  of  patients.  In  some 
institutions  a  pair  of  sheets  is  made  to  last  a  week  in  the  free  wards,  and  surgeons 
in  the  operating-rooms  are  compelled  to  wear  an  operating  gown  for  a  morning's  work 
without  change;  in  some  institutions  towels  are  distributed  most  begrudgingly,  the 
nurses  being  compelled  to  use  a  bath  towel  for  a  week  and  a  face  towel  for  half  as 
long.  In  some  institutions  free  patients  are  bathed  every  day  and  the  bedcloth- 
ing  is  changed  as  often.  Private  patients  are  given  all  the  linen  they  want,  which 
is  vastly  different  from  the  amount  they  actually  need,  and  interns  and  nurses  and 
administrative  officers  have  bath  towels  and  face  towels  daily.  In  some  places 
the  nurses  wear  their  uniforms  for  a  whole  week  and  their  aprons  for  three  days, 
while  in  other  institutions  they  are  given  three  uniforms  a  week  and  aprons  every 
day.  We  shall,  therefore,  not  attempt  to  fix  the  capacity  of  the  laundry  in  the 
institution  that  is  run  by  a  guiding  star  of  economy  rather  than  that  of  efficiency, 
nor  shall  we  be  obliged  to  calculate  for  the  institution  that  is  prodigal  with  its 
laundered  goods.  One  cannot  fix  any  definite  limit  to  the  bedclothing  and  body 
clothing  of  patients  in  the  hospital.  One  surgical  patient  may  need  ten  or  even 
twenty  changes  of  sheets  a  day,  and  in  the  well-conducted  hospital  will  have 
them.  Babies  that  are  properly  cared  for  must  have  sometimes  as  many  diapers 
as  one  every  half-hour.  But  we  can  fix  somewhat  a  fair  average  of  the  laundry  work 
in  the  well  parts  of  the  institution.  The  dining-tables  ought  certainly  to  be  changed 
( mee  every  day  and  the  napkins  as  well.  It  is  the  custom  in  many  places  to 
change  the  interns'  and  nurses'  sheets  twice  a  week,  making  the  top  sheet  of  to-day 
the  bottom  sheet  of  the  three  days  hence.  Pillow  slips  ought  to  be  changed  three 
times  a  week,  because  the  oils  in  the  hair  soil  them.  Interns'  white  uniforms  are 
difficult  to  launder,  and  should  be  done  by  hand,  although  a  large  percentage  of 
the  work  can  be  done  on  body  ironers,  which  would  leave  hand  work  for  the  finish- 
ing only.  Four  pairs  of  trousers  and  three  coats  a  week  are  quite  necessary  if  the 
young  men  are  to  make  a  neat  and  businesslike  appearance.  Undergraduate 
nurses  must  have  two  uniforms  a  week,  and  there  must  be  no  niggardliness  if  they 
need  a  third.  Some  nurses  are  much  neater  than  others  and  take  better  care  of 
their  clothes,  and  some  of  them  require  more  uniforms  because  of  the  nature  of  their 
work,  as,  for  instance,  in  the  children's  department.  In  the  surgical  departments 
and  die!  kitchens  the  clothes  can  he  protected  by  long  aprons,  dressing-gowns,  and 
operating-room  garments;  they  should  have  at  least  one  apron  and  clean  cuffs  and 
Collars  every  day  and  underclothing  twice  a  week.  Special  arrangements  should 
be  made  for  sanitary  napkins  for  the  nurses.      There  is  on  the  market  a  pad.  made 


602  OPERATION   OF   THE    HOSPITAL 

of  absorbent  cotton  and  gauze,  that  costs  in  large  quantities  about  1  cent,  and  if  the 
nurses  are  provided  with  these  it  will  contribute  to  lessen  the  amount  of  laundry  in 
towels  and  the  regular  napkins,  and  will  contribute  even  more  to  the  self-respect  of 
the  nurses  who  are  thus  provided. 

Head  nurses  who  wear  white  uniforms  should  have  three  a  week  if  they  are  to 
be  a  credit  to  the  institution. 

These  proportions  make  up,  with  variation  here  and  there,  the  chief  laundry 
articles  in  the  best-conducted  institutions  in  this  country,  and  it  is  upon  such  figures 
as  these  that  we  must  base  our  calculations  as  to  the  amount  of  work  the  laundry 
ought  to  be  asked  to  perform.  Also,  when  we  figure  laundry  work,  we  must  figure 
per  bed  of  the  hospital — that  is,  according  to  the  number  of  patients — it  being 
assumed  that  each  bed  requires  the  attention  of  a  given  amount  of  service  of  other 
people — nurses,  interns,  mechanics,  and  the  common  help — and  in  most  institutions 
this  is  figured  at  one  well  person  for  one  patient.  For  instance,  if  there  are  200 
patients  there  will  be  about  400  people  in  the  establishment  for  whom  the  laundry 
must  be  operated.  Of  course,  it  is  well  understood  that  the  proportion  of  well  people 
to  the  number  of  beds  grows  with  the  size  of  the  institution;  that  is,  a  hospital  of 
50  beds  may  require  25  people  to  serve  it.  When  the  size  of  the  hospital  grows  to 
200  beds,  the  number  of  help  will  be  about  equal,  and  beyond  that  the  number  of 
well  people  will  exceed  the  number  of  beds. 

Very  much  might  be  written  concerning  the  number  of  pieces  per  patient  allow- 
able under  modern  hospital  conditions  where  both  patients  and  well  people  are 
accorded  adequate  laundry  service.  There  is  much  literature  on  the  subject, 
some  of  it  not  very  recent,  some  of  it  wholly  unreliable  or  taken  from  seriously 
questionable  calculations,  and  some  of  it  presenting  figures  of  actual  accomplish- 
ment so  ridiculously  low  as  to  be  unworthy  of  consideration.  It  cannot  profit  us, 
therefore,  to  dilate  upon  such  statistics,  and  we  shall  content  ourselves  with  a  very 
brief  review  of  the  figures  of  two  institutions,  one  the  Mount  Sinai  Hospital  in 
New  York,  conceded  to  be  exceptionally  well  conducted,  and  the  other  the  Michael 
Reese  Hospital  in  Chicago,  where  it  may  be  stated  without  offense  a  serious  effort  is 
made  to  give  a  high  order  of  service,  and  in  which  the  figures  of  accomplishment 
have  been  faithfully  gathered. 

At  Mount  Sinai  the  figures  taken  for  the  purposes  of  this  section  were  as  follows; 

Medical  pavilion  (150  beds) 12,000  pieces  per  week. 

Surgical  pavilion  (150  beds) 15,000       "  " 

Private  patients  (40  to  50  beds) 6,000  to  8,000  pieces 

per  week. 
Children's  pavilion  (72  beds) 8,000  pieces  per  week. 

Dr.  Goldwater,  in  his  estimates  so  kindly  prepared,  carries  his  figures  to  the 
well  people  in  the  establishment,  showing  a  total  of  70,000  pieces  turned  out  of  the 
laundry  per  week,  or  160  pieces  per  patient,  not  per  person,  or  nearly  23  pieces  per 
patient  per  day. 

In  the  Michael  Reese  Hospital  the  figures  are  taken  for  a  period  when  there 
were  290  patients  per  day,  and  well  persons  numbering  310,  of  whom  110  were 
nurses,  20  interns,  20  executive  officers  and  dependents,  10  orderlies,  and  40  help, 
mostly  maids,  the  balance  of  the  help  attending  to  their  own  laundry.  Of  the 
patients,  62  were  children,  there  were  3  cases  of  obstetrics  per  day,  37  private-room 
patients,  and  the  balance  were  about  equally  divided  between  medical  and  surgi- 
cal, with  an  average  of  15  major  operations  daily.  For  this  period  the  laundry 
amounted  to  an  average  of  37,000  pieces,  running  slightly  more  some  weeks  and  less 


THE    [NSTITUTION    LAUNDRY  603 

at  other  times.  This  gives  an  average  of  127  pieces  per  patient  per  week,  or  about 
18  per  day.  When  it  is  considered  that  more  than  100  of  the  help  had  their  laundry 
done  elsewhere  the  actual  work  per  patient  will  he  somewhat  increased,  making  it 
closely  approximate  that  of  Mount  Sinai  Hospital.  We  may  feel  justified,  there- 
fore, in  saying  that  20  pieces  per  patient  per  day  is  a  fair  average  for  the  modern 
hospital. 

Laundry  Machinery. — The  size  and  character  of  machines  needed  in  the  laun- 
dry will  depend  very  much  upon  the  makes  of  the  machines  and  the  methods  em- 
ployed in  the  washing  processes;  in  some  laundries  each  washerful  is  given  a  thor- 
ough rinsing  with  cold  water  in  the  washers  in  motion,  for  the  purpose  of  loosen- 
ing the  soluble  dirt  before  the  hot  water  and  soapsuds  are  put  in,  and  in  some 
laundries  the  changing  of  the  washerful  requires  a  great  deal  more  time  than  in 
other  places,  but  it  may  be  fair  to  calculate  that  a  washer  will  be  at  work  half  an 
hour  and  stopped  during  the  changing  process  for  fifteen  minutes;  that  is,  a  washer 
will  wash  its  capacity  of  clothing  every  forty-five  minutes. 

Washing  machines  are  standard,  being  of  the  revolving  and  cylindric  type,  and, 
indeed,  all  laundry  machinery  is  made  in  standard  sizes  and  of  standard  types. 
Not  very  much  is  to  be  said  about  washers,  excepting  that  the  smaller  the  units  the 
more  convenient  will  they  prove  in  the  varied  work  of  hospitals.  In  the  larger 
institutions  it  is  well  to  have  one  or  two  large  washers  for  the  heavier  fiat  work,  like 
sheets,  spreads,  slips,  and  table-cloths,  and  smaller  machines  for  most  of  the  other 
stuff.  These  smaller  washers  are  36  inches  in  diameter  and  48  inches  long  inside 
the  cylinder.  Those  made  of  metal,  mostly  brass  at  all  points,  that  come  in  con- 
tact with  water,  are  by  far  the  most  economic,  though  the  first  cost  is  nearly  double 
that  of  the  all-wood  machines.  Wood  has  a  great  tendency  to  pulp  and  soften  under 
the  combined  action  of  heat  and  the  various  chemicals,  such  as  soap,  soda,  and  acids, 
and  wears  out  so  quickly  that  it  is  in  no  way  comparable  to  the  machines  made  all 
metal.  A  while  ago  there  was  complaint  that  the  metal  parts,  especially  the  lighter 
brass  of  the  cylinder,  would  sometimes  crack  or  break,  leaving  sharp  edges  to  tear 
the  clothing,  but  this  defect  has  been  remedied  in  the  modern  washers  and  the 
complaint  no  longer  holds.  Yet  a  small  washer,  of  about  half  the  capacity  of  the 
above  size  referred  to,  is  a  requirement  of  every  institution  for  handling  the  ex- 
tremely dirty  pieces,  such  as  kitchen  cloths,  etc. 

The  flat-work  ironer  is  the  most  important  item  of  machinery  in  the  laundry. 
As  the  ironer  has  capacity,  so  the  laundry  will  have  capacity  or  the  want  of  it,  and 
one  of  the  commonest  mistakes  of  those  charged  with  the  equipment  of  the  insti- 
1  ut inn  is  in  the  purchase  of  an  ironer  having  a  capacity  inadequate  to  the  work  to 
be  done.  Take,  for  instance,  the  100-inch  three-roll  ironer  of  the  Hagen  type,  a 
most  formidable  looking  machine,  one  that  has  a  capacity  to  move  at  the  rate  of 
14  feet  per  minute,  and  it  costs  about  81000.  If  it  is  crowded  beyond  its  capacity 
it  will  not  iron  the  clothes  properly  and  will  not  dry  them.  Besides  this,  the  Hagen 
type  of  ironer  seems  not  to  be  planned  on  logical  principles,  since  its  action  is  based 
on  a  dragging  motion  of  the  goods  through  rolls  that  work  in  hollow  grooves,  cog- 
wise;  this  dragging  motion  has  the  effect  of  stretching  the  fabric,  and  when  the  rolls 
or  grooves  or  both  become  hard,  as  they  do,  the  goods  will  be  handled  roughly  and 
will  eventually  tear  apart,  especially  at  the  seams. 

The  next  size  of  ironer — that  is,  the  four-roll  machine,  100  inches  wide — covers 
a  moving  surface  of  40  feet  per  minute,  and  will  thus  iron  more  than  three  times 
the  amount  of  clothing  that  will  be  done  by  the  smaller  machine,  and,  moving 
faster  as  it  does  and  with  more  than  double  the  surface,  the  drying  out  is  accom- 
plished quicker,  and  hence  the  ironing  is  much  better  performed.     This  machine 


604 


OPERATION    OF    THE    HOSPITAL 


costs  about  $1800,  but  it  is  well  worth  the  difference  in  price  to  those  who  can  use 
that  size  of  machine. 

The  newest  type  of  ironer,  and  that  which  seems  destined  to  supersede  all 
others,  is  the  rotary  machine,  composed  of  a  large  steam-heated  cylinder  and  with 
a  series  of  smaller  padded  rolls  set  at  equal  distances  about  it,  and  fixed  to  revolve 
each  on  its  own  axis  in  consonance  with  the  larger  cylinder.  So  important  is  this 
principle  of  ironing  clothes  that  a  line  drawing  is  presented  showing  the  mechanism 
(Fig.  196).  This  type  of  machine  is  not  peculiar  to  any  one  company,  but  is  made 
by  the  two  principal  ones,  and  is  coming  into  common  use.  The  better  machines  of 
this  type  have  cylinders  48  inches  in  diameter  by  100  to  120  inches  in  length,  but 
all  manufacturers  make  machines  with  smaller  diameter  cylinders,  the  general 
principles  of  which  are  virtually  the  same  as  the  larger  machine,  and  which  make  it 
possible  for  the  smaller  institutions  to  be  provided  with  a  cylinder  type  of  machine 
that  will  meet  their  needs  and  purse. 


BlMJMT 


Fig.  196. — Details  of  Trojan  mangle. 

Electric  Versus  Gas  Irons. — A  great  many  of  the  clothes  must  be  ironed  by 
hand,  and  electric  manufacturers  have  been  insisting  for  some  years  that  electric 
irons  are  par  excellence,  the  most  advantageous  for  use  in  the  laundry,  the  chief 
reason  being,  to  their  way  of  thinking,  that  the  operator  does  not  have  to  stop  to 
change  her  irons  as  she  proceeds.  This  process  of  reasoning  does  not  work  out  in 
actual  experience,  for  the  reason  that  institution  laundries  do  not  give  as  much 
attention  to  the  uniform  dampening  of  their  goods,  therefore  endeavor  to  iron  goods 
that  are  too  wet  for  practical  use  with  electric  irons.  Under  these  conditions  it  is 
impossible  to  keep  an  electric-heated  iron  hot  enough  to  do  constant,  steady  work. 
The  dampness  of  the  cloth  cools  it  far  more  quickly  than  the  electric  current  can  heat 
it;  there  is  the  other  extreme,  of  course,  which  is  the  main  reason  why  manufacturers 
do  not  put  in  a  sufficient  amount  of  electric  resistance  to  keep  the  iron  at  a  proper 
temperature;  if  the  iron  is  so  built  that  it  will  keep  sufficiently  hot  under  condi- 


THK     INSTITUTION    I..UNDUY 


li()-l 


tions  as  they  prevail  in  a  large  laundry,  when-  the  women  are  expected  to  keep  the 
iron  on  damp  cloth  all  the  time,  then  thai  same  iron  would  burn  up  goods  in  the 
hands  of  the  average  housewife  who  is  doing  her  home  work  with  an  occasional 
stop.  There  may  come  a  time  when  some  sort  of  electric  device,  in  the  nature  of 
a  thermostat,  can  be  put  into  laundry  irons  to  keep  them  at  exactly  the  right 
temperature,  but  until  thai  time  is  come  electric-heated  irons  must  be  assumed  to 
be  entirely  out  of  the  question  for  the  hospital  laundry.  The  old-fashioned  6-  or 
7-pound  hand-iron  has  not  been  improved  on. 

A  good  deal  of  the  laundry  work  must  be  done  on  body  ironers,  such  as  starched 
shirts,  interns'  and  nurses'  uniforms,  and  there  has  been  some  discussion  as  to  the 
relative  merits  of  electricity  and  gas  for  heating  these  machines.  Those  of  us  who 
have  tried  both  kinds  are  quite  satisfied  that  gas-heated  body  ironers  are  the  best, 
and  electricity  is  incapable  of  giving  the  right  temperature,  for  the  same  reason  that 
operates  in  the  case  of  hand-irons;  if  the 
operator  is  busy,  and  has  the  damp  garments 
constantly  against  the  iron,  it  will  be  too  cold 
to  do  proper  work,  and,  on  the  other  hand, 
the  fabrics  will  be  burned  if  the  work  slows 
up  or  if  the  goods  are  dry  when  they  are 
being  ironed. 

For  all  these  smaller  machines  the  manu- 
facturers are  working  toward  steam-heating 
devices  to  replace  both  gas  and  electricity, 
but  steam-heated  machines  cannot  be  brought 
to  the  high  temperature  with  electricity,  to 
say  nothing  of  the  higher  temperature  of  gas, 
consequently  these  machines,  from  a  stand- 
point of  saving  of  electricity  or  gas,  will  be 
desirable,  but  not  from  a  standpoint  of  satis- 
factory  service,  for  it  will  take  much  longer  to 
do  the  work  on  the  same  classes  of  goods  with 
strain  for  heat.  Where  electricity  is  available 
for  other  purposes  in  the  institution  it  would 
undoubtedly  be  cheaper  to  use  than  gas,  at 
average  prices,  but  for  its  inefficiency  as  indi- 
cated above;  but  steam  is  also  always  avail- 
able in  the  laundry,  and  will  prove  far  cheaper 
than  either  if  mechanism  can  be   developed 

to  employ  it.  There  is  a  new  steam-heated  body  ironer  on  the  market  that  has 
arrived  at  a  commercial  stage  of  development,  but  its  capacity  is  20  per  cent, 
less  than  the  same  type  of  machine  would  lie  heated  by  electricity,  anil  33 &  per 
cent,  less  than  heated  by  gas.  Tucking,  fluting,  and  edging  devices  are  too  small 
to  admit  of  steam-coil  heating. 

Reverting  to  the  body  ironers.  the  best  form  is  that  known  as  the  single-tread 
reversible  type,  because  it  swings  with  one  motion  and  permits  the  operator  to 
use  one  foot  for  supporting  the  body,  and  is  consequently  easier  to  handle,  giving 
the  operator  practically  nothing  to  do  but  attend  to  her  garment. 

The  Laundry  Driers.—  The  driers  are  of  importance.  The  ordinary  sectional 
driers  will  he  used,  of  course,  for  most  gooils  intended  to  be  hand  or  body  ironed, 
but  for  garments  that  air  to  be  returned  unironed,  such  as  operating-room  gowns, 
visitors'  coats,  underwear,  bath,  massage   and    roller   towels,  hags,    and    rags,   the 


Fig.  197. — Rotary  tumbler.  Dia- 
gram, showing  circulation:  1.  An  in- 
take;  2,  steam  coils;  3,  air  passage  to 
fan;  4,  ventilating  fan;  5,  air  passage  to 
tumbler  cylinder;  6,  tumbler  cylinder; 
7,  damp  air  discharge. 


606 


OPERATION    OF   THE    HOSPITAL 


so-called  "dry-room  tumbler"  or  rotary  steam-coil  drier  is  much  better,  will  save 
time,  and  bring  the  articles  back  in  far  better  condition.  This  drier  is  also  used 
for  drying  articles  intended  to  be  ironed,  and  that  have  been  starched  in  machine 
starchers.  This  double  process  of  starching  is  an  improvement  over  the  washer 
starching  as  it  saves  a  double  extracting  process,  and  likewise  saves  the  time 
necessary  to  hang  in  the  sectional  driers  and  to  dampen  for  ironing.  As  this  rotary 
drier  is  a  special  piece  of  machinery,  not  very  commonly  understood  in  principle, 
it  is  reproduced  in  Fig.  197. 

Wringers  which  the  laundry  machinery  manufacturers  call  "extractors,"  made 
to  revolve  at  a  high  centrifugal  speed  to  extract  the  superfluous  water,  is  a  very 
important  item  in  every  laundry.  On  flat  pieces,  such  as  sheets  of  single  thick- 
ness, a  good  extractor  should  remove  in  fifteen  minutes'  running  time  66f  per  cent. 


w///////////////////^^^^ 


ENTRANCE 


— r=2 


zf= 


T        <i     f 


I     r       I  in? 


L, 


-~—*"*~^ 


i 


■yJ//^      "       |„///,„/JI 


Fig.  198. — Plan  for  100-bed  laundry;  clean  clothes  never  cross  an  infected  trail. 


of  the  moisture,  leaving  33  \  per  cent,  to  be  taken  out  in  the  ironing  process.  On 
such  pieces  as  toweling  it  should  remove  about  60  per  cent,  of  the  moisture,  and  it 
will  be  understood  that  unless  this  moisture  is  removed  in  the  extractor  the  capacity 
of  the  ironing  and  drying  machines  will  be  that  much  retarded.  The  extractor  is 
located  in  the  washing  department,  is  operated  by  the  same  men  who  do  the  wash- 
ing and  extracting,  and  consequently  sufficient  machines  of  the  proper  kind  should 
be  installed  to  see  that  this  percentage  is  maintained,  for  if  the  removing  of  this 
superfluous  moisture  is  left  to  the  ironing  and  drying  machines  it  means  additional 
expense  for  help  to  feed  the  goods  into  the  machine,  to  supply  steam  to  overcome 
this  moisture,  and  diminishes  the  capacity  of  both  the  ironer  and  dryer,  making 
it  necessary  to  give  longer  time  for  each  piece  to  be  dried  than  would  be  necessary 
through  proper  extraction. 


THE    INSTITUTION    LAUNDRY 


607 


Space  for  Machinery.— There  is  hardly  a  laundry  in  the  country  that  has  ade- 
quate space  in  which  to  perform  the  work  of  which  the  machinery  is  capable;  there 


—    LAUND    E.Y   - 


Fig.  199.— Floor-plan  for  large  laundry.     Everything  enters  one  door,  makes  a  complete  circuit 
of  the  room  without  crossing  an  infected  trail. 

is  never  enough  room  for  the  help  to  move  about  and  do  the  work.     Very  few  people 
at  the  head  of  institutions  give  very  much  thought  to  the  laundry,  and  they  build 


608  OPERATION   OF   THE    HOSPITAL 

almost  everything  first,  and  expect  the  laundry  to  occupy  space  that  is  not  adequate 
for  anything  else — some  basement  room,  or  a  half-story  of  the  power  house,  are 
usually  considered  good  enough  for  the  laundry.  The  laundry  ought  to  occupy 
one  of  the  most  select  positions  in  the  whole  establishment.  In  the  first  place,  the 
help  in  laundries  are  entitled  to  some  decent  consideration  in  regard  to  their 
health  and  the  conditions  under  which  they  labor. 

There  is  a  constant  atmosphere  of  vapor  in  every  laundry,  due  to  the  drying  out 
of  wet  garments,  and  the  steam  and  hot  water  from  the  washers  and  driers.  The 
floors  of  the  modern  laundry  are  usually  of  concrete,  and  are  made  so  that  there 
are  runways  for  the  water  into  the  sewers  at  different  points,  and  an  immense 
amount  of  evaporation  goes  on  from  these  runways  also.  It  can  hardly  be  called 
a  healthy  occupation  when  people  are  asked  to  work  in  an  environment  of  cold 
vapor.  Therefore,  the  ventilation  of  the  laundry  ought  to  be  better  than  that  in 
any  other  part  of  the  house,  and  it  ought  to  be  an  artificial  ventilation,  so  that  there 
will  not  be  constant  drafts  from  one  side  of  the  room  to  the  other  that  will  chill 
the  workers,  whose  clothing  will  be  clamp  at  best. 

A  very  fair  calculation  of  space  for  the  laundry  figures  out  at  about  10  square 
feet  per  bed  of  the  institution.  If  there  is  a  greater  amount  of  space  than  this  avail- 
able it  would  be  advantageous,  and  a  good  many  hospital  administrators  insist 
upon  12  feet.  As  a  matter  of  fact,  take  the  hospital  and  hotel  laundries  all  over  the 
country,  and  they  will  not  average  more  than  5  or  6  feet  of  space  under  this 
calculation,  which  is  one  reason  why  laundry  work  is  so  indifferently  done,  and 
why  the  conditions  in  the  laundries  are  so  bad. 

The  conveniences  for  washing  make  it  necessary  that  the  machinery  shall  be 
installed  in  certain  ways,  and  that  there  shall  be  a  certain  arrangement  through- 
out. The  accompanying  plans  illustrate  the  ideas  of  some  practical  laundrymen, 
working  in  conjunction  with  hospital  architects  and  manufacturers  of  laundry 
machinery.  These  plans  contemplate  two  different  sizes  of  plants,  made  for  the 
purposes  of  this  section  by  the  Troy  Laundry  Machinery  Co.  in  conjunction 
with  the  author.  The  figures,  sizes,  and  conditions  have  been  carefully  edited  by  the 
author,  the  architect,  and  a  competent  laundryman  jointly,  and  it  is  believed  that 
they  will  be  found  to  represent  actual  requirements  for  the  general  hospital  of  the 
capacities  given.  Those  who  have  special  conditions,  as,  for  instance,  fewer  units 
and  larger  amounts  of  each,  may  be  able  to  use  one  or  the  other  of  these  plans, 
making  the  proper  changes. 

Arrangement  of  Laundry  Space. — All  laundry  goods  must  be  taken  through 
one  entrance  and  out  another,  so  that  no  clean  linens  will  come  in  contact  with  the 
trail  of  soiled  goods.  Figure  198  shows  such  an  arrangement  for  a  small  laundry, 
and  Fig.  199  shows  a  floor  plan  for  an  institution  of  300  or  more  patients.  In  both 
illustrations  an  attempt  is  made  to  show  the  direction  of  travel  of  flat  work  and  hand 
work  separately. 

Laundry  Rules. — It  will  not  be  advantageous  to  go  into  questions  of  detail  in 
regard  to  doing  laundry  work,  but  there  are  a  few  fundamental  points  that  might 
be  well  formulated  into  general  rules: 

(1)  All  water  for  laundry  purposes  should  be  filtered,  and  the  charac- 
ter of  the  water  should  be  well  known;  if  it  is  hard,  a  suitable  softener 
should  be  used  in  the  same  way  that  chemicals  are  used  to  prevent  scale 
in  boilers.  Provision  should  be  made  at  the  very  start  for  the  supplying 
of  abundance  of  hot  water,  and  the  same  maintained  at  a  temperature 
of  at  least  180  degrees;  this  water  is  generally  provided  in  abundant- 
quantities  by  the  exhaust  from  the  power-plant  engines.     By  having  hot 


THE    I.XSTITI  TION    LAUNDRY  lid'J 

water  of  the  above  or  greater  temperature  it  eliminates  to  some  extent  the 

use  of  live  steam  in  the  washing  machines  themselves,  which,  on  account 
of  this  pressure  and  force,  is  injurious  to  the  linen.  There  is  an  estab- 
lished law  in  England  which  prevents  a  public  laundry  from  operating 
washing  machines  having  steam  pressure  of  more  than  15  pounds  to  each 
washer,  and  should  a  customer  be  able  to  prove  that  a  higher  temperature 
was  maintained  he  could  sue  and  recover  for  damages  to  his  linen,  and  high- 
pressure  steam  blowing  into  the  washing  machine  will  damage  the  goods. 
In  addition,  it  has  a  tendency  to  set  the  soap  and  other  ingredients  in  the 
goods,  which  soon  has  a  tendency  to  turn  them  gray,  therefore,  a  very  im- 
portant part  of  the  laundry  should  be  an  abundance  of  hot  water  a1  a 
high  temperature. 

(2)  To  minimize  the  care  with  individual  motors  for  each  unit  or 
machine  required  in  present-day  practice  it  is  advisable  that  the  equipment, 
particularly  the  washing  department,  be  operated  from  a  main  driving 
shaft  by  belts  from  shaft  to  power  pulleys  on  each  machine.  On  larger 
machines,  such  as  flat-work  ironers  and  rotary  driers,  the  individual 
motors  are  best,  as  these  would  not  be  working  under  the  severe  strain 
or  conditions  that  they  would  be  in  the  washing  department  on  account 
of  the  heat,  steam,  moisture,  etc.  The  laundry  machinery  manufacturers, 
however,  are  bringing  to  perfection  gang  drives  in  the  wash-room,  by 
which  shafting,  that  will  operate  these  machines,  is  a  part  of  the  machine, 
and  can  Ik-  connected  in  such  a  way  as  to  make  a  great  saving  of  space 
and  eliminate  the  use  of  belts,  with  the  exception  of  one  main  drive,  which 
can  be  of  double-thick  belt  of  the  heavy  grade. 

(3)  Body  ironers  will  give  a  higher  efficiency  if  heated  by  gas,  and  hand- 
irons  by  gas  stoves  made  for  this  purpose,  if  these  can  be  properly  in- 
stalled. Collars,  cuffs,  and  shirts  can  be  ironed  on  machines  built  for  that 
purpose,  and  a  machine  known  as  a  combined  ironer,  having  interchange- 
able surface  boards  for  collars,  cuffs,  and  shirts,  is  best  for  the  purpose, 
as  this  machine  is  inexpensive  in  comparison  with  individual  machines 
for  each  class  of  work,  and  in  the  average  hospital  laundry  is  in  use  but  a 
short  period  of  each  day. 

(4)  Each  piece  in  the  bags  of  individuals  must  be  plainly  marked, 
either  with  indelible  ink  or  with  a  tape  sewed  into  the  piece  containing 
the  worked-in  name.  Indelible  ink  should  be  purchased  of  a  laundry 
supply  dealer  which  does  not  require  a  hot  iron  to  set.  This  is  a  com- 
mon fault  with  hospitals.  Goods  found  not  to  be  plainly  and  indelibly 
marked  at  the  time  of  sorting  should  be  thrown  aside  without  being 
laundered.  Torn  articles  discovered  at  the  time  of  sorting  should  not 
be  laundered. 

(5)  Each  individual  bundle  or  bag  should  be  tagged  on  the  outside, 
and  this  tag  should  contain  a  lis!  of  the  garments  within,  to  be  cheeked 
from  by  the  sorter.  If  the  list  is  found  to  be  incorrect,  the  articles 
should  be   returned    to    the    bag  and    the    bag  returned  to  the  owner  for 

correction. 

There  should  be  separate  days  for  doing  the  laundry  for  each  class  of  residents 
in  the  institution,  ami  this  rule  should  extend  to  the  time  at  which  the  bundles 
should  be  ready  for  the  linen  collector.  If  the  bundles  are  not  ready  on  time 
they  should  be  refused  when  presented.  Arrangements  can  lie  worked  nut  -,,  thai 
the  delivery  of  clean  linen  and  the  collection  of  the  soiled  linen  can  be  made  at  one 


610  OPERATION    OF   THE    HOSPITAL 

trip,  but  care  should  be  taken  that  infected  goods  are  not  brought  in  contact  with 
goods  that  have  been  cleansed.  Complaints  concerning  lost  or  damaged  articles 
should  be  made  at  once  in  the  main  linen  room.  If  complaints  are  not  given  im- 
mediate and  satisfactory  attention  the  matter  should  be  referred  to  the  super- 
intendent of  the  hospital. 

The  wash  of  executive  officers  of  the  institution  should  be  done  entirely  sepa- 
rately.    The  interns'  and  the  nurses'  wash  should  be  done  separately. 

All  stained  and  badly  soiled  goods  should  be  done  separately,  but  care  should 
be  taken  to  see  that  all  infected  articles  have  been  sterilized  to  meet  the  demands 
of  the  laboratory  of  pathology  before  putting  them  into  the  washers,  because  the 
usual  washing  process  cannot  be  counted  on  to  destroy  harmful  bacteria. 

It  will  be  advantageous  to  treat  each  ward  unit  separately,  so  that  each  may 
have  its  own  supply  marked  in  detail,  according  to  its  regular  designation  in  the 
hospital.  In  this  way  head  nurses  can  be  held  to  account  for  continued  staining 
and  tearing.  If  each  nurse  has  a  separate  supply  she  will  take  an  interest  in  keep- 
ing it  in  good  order,  but  all  soiled  linens  from  all  parts  of  the  institution  should  be 
collected  and  checked  by  a  person  or  persons  regularly  employed  for  that  pur- 
pose, and  duplicate  checking  lists  should  be  kept  as  a  bookkeeping  account  with 
each  department  in  the  hospital.  Clean  linen  should  be  checked  into  each  depart- 
ment in  the  same  way  and  by  the  same  people.  According  to  this  plan,  the  only 
linens  that  would  go  to  a  central  linen  room  would  be  table  linen,  roller  towels, 
and  such  articles. 

A  minimum  of  soda  and  bleach  should  be  used  with  colored  goods  to  avoid 
fading.  Tepid  water  only  should  be  used  in  washing  nurses'  colored  uniforms. 
Flannel  underwear  and  blankets  should  be  washed  with  a  mild,  absolutely  neutral 
soap,  and  in  either  cold  or  tepid  water,  but  the  temperature  of  the  water  must 
never  vary  during  the  process.  These  flannel  goods  should  be  washed  quickly,  as 
continued  rolling  in  the  machine  tends  to  shrink  woolens.  Ward  linens  should  be 
sorted  carefully  before  going  into  the  washers,  so  that  the  badly  soiled  and  stained 
goods  will  not  go  into  the  washers  with  those  only  slightly  soiled,  and  these  badly 
soiled  goods  must  be  treated  by  hand  before  going  into  the  washers. 

All  ward  linens  must  have  a  five-minutes'  rinse  in  cold  water  and  soda  in  the 
washers  before  the  steam  and  soap  are  added. 

Goods  must  be  thoroughly  rinsed  with  water  before  they  are  taken  from  the 
washers,  else  there  will  be  a  tendency  to  turn  yellow. 

Ward  linens  should  be  bleached  not  oftener  than  once  a  month,  and  great  care 
should  be  taken  to  see  that  the  bleach  is  in  thorough  solution  before  using. 

Table  linens  must  be  washed  separately  and  bleached  once  each  week.  An 
occasional  oxalic  bath  should  be  given,  but  a  thorough  and  complete  hot  rinsing 
should  follow  to  avoid  injury  to  the  goods  by  the  acid. 

Sectional  dry  rooms  may  be  used  for  all  starched  clothing,  but  operating-room 
coats  and  gowns,  patients'  bed  gowns,  and  other  articles  that  are  not  to  be  stiffened 
may  be  dried  more  advantageously  in  rotary  driers,  as  the  revolving  motion  will 
serve  to  prevent  wrinkling  and  dry  more  uniformly. 

Linens  should  never  leave  the  laundry  until  thoroughly  dry,  nor  should  the 
linens  be  in  constant  circulation.  There  should  be  plenty  of  reserve  supply,  so 
that  clean  linens  may  rest  on  the  shelves  for  at  least  one-half  the  time,  and  this 
will  serve  the  double  purpose  of  meeting  the  emergency  of  a  possible  breakdown 
in  the  laundry,  and  to  insure  against  that  physical  agent  not  well  understood  in 
detail,  but  recognized  in  everything  usable  from  people  to  metal,  and  which  we  call 
fatigue. 


THE    INSTITUTION    LAUNDRY  Oil 

Cost  of  Laundry  Work.—  Figures  of  cost,  even  for  commercial  laundry  work, 
arc  extremely  difficult  to  obtain,  and  a  careful  search  of  the  literature  and  confi- 
dential inquiry  of  the  laundry  machinery  makers  have  failed  to  discover  any  figures 
worthy  of  credence.  In  the  Michael  Reese  Hospital  very  careful  data  have  been 
kept  for  one  year,  and  the  subjoined  tables  give  the  results  which  may  be  taken  as 
accurate  for  that  institution.  No  two  institutions  wall  work  under  exactly  the 
same  conditions,  and  hence  costs  differ,  depending  partly  on  the  specific  economics 
practised,  the  conveniences  of  equipment  and  operation,  the  character  of  the 
work,  the  amount  of  hand  work,  and  the  efficiency  of  the  performance. 

The  Michael  Reese  Hospital  is  a  general  hospital,  having  at  the  time  of  this 
test  work  a  surgical  department  of  fifteen  major  operations  per  day,  a  medical 
service  of  about  50  patients,  a  gynecologic  service  of  about  25  patients,  a  children's 
hospital  of  65  beds,  and  a  maternity  service  of  3  cases  per  day.  There  were  110 
pvipil  nurses,  12  head  nurses,  20  interns,  and  about  160  common  help,  some  of  whom 
did  their  own  laundry  work.  The  average  total  number  of  patients  for  the  period 
was  290  per  day. 

In  the  laundry  there  were  15  women  employed,  1  male  helper,  and  a  head 
laundryman. 

The  machinery  consisted  of: 

2  largo  washers.  1  Triplex  100-inch  3-roll  ironer. 

2  medium  washers.  1  gas-heated  body  ironer. 

'_'  extractors.  2  sectional  driers. 

1  25-gallon  starch  kettle. 

The  power  was  taken  from  the  general  plant  of  the  institution,  aggregating 
600-horsepower  boiler  capacity  in  three  boilers,  two  of  which  were  in  use.  the 
other  being  held  in  reserve.  The  cost  of  laundry  power  included  the  pro  rata  cost 
of  operating  the  plant  including  everything.  There  was  no  cost  for  water,  as  hos- 
pitals get  their  water  from  the  city  free. 

Number  of  pieces  turned  out  for  290  patients  per  year 1,924,000 

Number  of  pieces  turned  out  for  290  patients  per  week 37,000 

Number  of  pieces  turned  out  for  290  patients  per  day 5,2S6 

Number  of  pieces  turned  out  for  1  patient  per  day IS  -+- 

Cost  of  Mali  rial: 

Soap $1071.00 

Starch 181.50 

Soda 135.00 

Sundries 106.7-1         S1494.24 

Cost  of  Labor  and  Board: 

Wages  of  help S5417.S3 

Board  of  help 2171.50        $7589.33 

Total  cost  of  laundry  for  290  patients  per  year 110,090  B  I 

Total  cost  of  laundry  for  290  patients  per  day 27.645 

Total  cost  of  laundry  for  1  patient  per  day. .095 

Total  cost  per  piece  80.0052,  or  52  cents  per  hundred. 

I',  /v,  ntagi  of  I  'ost  lit  mixed: 

1  abor 53T'%  per  cent. 

Board 21,^         " 

Supplies        14-rV        " 

Steam 5^        " 

Electricity 4^0        " 


612  OPERATION    OF   THE    HOSPITAL 

Cost  of  Electric  Power: 

Average  amperes 55 

Average  volts 222 

Average  watts  per  hour 12,220 

Watts  for  eight  hours 97,760 

Kilowatt  hours 98 

Cost  per  kilowatt  hour S0.0133 

Cost  of  electric  power  per  day 1.1433 

Cost  of  Steam  Power: 

Steam  used  on  washers 19.5  H.  P. 

Steam  used  on  ironers  and  dry  rooms 47.0      " 

Steam  used  for  heating  water  from  70°  F.  (6000  gallons) 120.0      " 

Total 186.5      " 

Cost  of  steam  per  H.  P $0.0086 

Cost  of  186.5  H.  P.  per  day 1.6163 

One  of  the  results  of  the  careful  examination  of  laundry  figures  cited  here  was  the 
discovery  that  high-pressure  steam  for  water  heating  was  extravagance  and  waste. 
The  steam  figures  should  not  have  been  more  than  10  per  cent,  of  what  they  were, 
and  the  installation  of  an  adequate  heater,  at  an  expense  of  $500,  in  which  nothing 
but  an  exhaust  steam  was  employed,  would  have  cut  this  item  of  cost  to  one-tenth 
of  that  quoted.  Indeed,  since  all  surplus  exhaust  steam  is  wasted,  the  utilization 
of  such  surplus  for  heating  the  laundry  water  would  cost  absolutely  nothing.  It 
is  in  such  items  as  these  that  laundry  economies  are  possible. 

Handling  the  Linens. — If  a  definite  system  of  checking  of  goods  intended  for 
the  laundry  can  be  utilized,  so  that  we  may  know  at  all  times  exactly  the  location 
and  distribution  of  the  supply,  more  than  one-half  of  the  difficulties  attendant  on 
institution  laundry  work  will  have  been  solved,  and  if  a  bookkeeping  system  can 
be  established,  so  that  a  constant  vigilance  can  be  maintained  over  every  section 
of  the  institution  at  all  times  in  regard  to  the  laundry  supplies,  the  laundry  will 
not  be  the  bugaboo  that  it  has  been,  and  will  continue  to  be,  to  most  of  us. 

An  adequate  checking  system  presupposes  arrangements  in  the  architecture 
of  the  building  that  will  lend  themselves  to  such  a  system.  So  important  is  such 
a  system  regarded  that  an  attempt  has  been  made  to  illustrate  the  circulation  of 
the  laundry  supply  in  Fig.  200. 

It  is  intended  in  this  illustration  to  show  the  journey  of  an  article,  beginning 
in  the  main  linen  room  of  the  institution  to  the  auxiliary  linen  room  of  the  depart- 
ment in  which  it  is  to  be  used;  from  there  to  the  bed,  from  the  bed  to  the  soiled  linen 
bag,  thence  to  the  truck,  to  the  elevator  or  chute,  thence  to  the  counting-room  at  the 
bottom  of  the  house,  illustrated  in  the  section  on  Equipment  elsewhere,  from  the 
counting-room  to  the  laundry,  and  thence  back  either  to  the  main  linen  room  or  to 
the  supply  rooms  in  the  several  departments  of  the  institution. 

To  make  this  system  comprehensive  and  workable  there  should  be  a  carbon-copy 
checking  list.  The  fist  should  be  different  for  each  department  of  the  institution, 
and  each  one  should  contain  all  the  articles  that  may  by  any  chance  be  sent  from 
that  department. 

The  soiled  linens  from  a  department  may  be  gathered  by  the  laundry  collectors 
in  the  large  laundry  bags  that  are  used  as  linen  receptacles  on  the  wards  or  in  the 
slop-sink  rooms.  These  bags  are  taken  to  the  counting-room,  and  the  list  book 
turned  over  to  the  counters.  The  various  articles  are  thrown  into  their  several 
bins  in  the  counting-room  from  a  central  table,  this  equipment  being  shown  in  the' 
section  on  Equipment.  The  units  in  each  bin  are  then  counted,  the  number  of 
sheets,  spreads,  cases,  towels,  and  so  on  are  checked  on  the  list.     The  articles 


THE    INSTITUTION    LAUNDRY 


G13 


614  OPERATION    OF   THE    HOSPITAL 

are  then  thrown  back  into  the  bags,  the  original  copy  is  returned  to  the  head  nurse 
in  the  department  from  which  the  goods  came,  and  the  duplicate  is  forwarded  to 
the  laundry  with  the  linen  bags  to  be  used  in  the  laundry  for  purposes  of  checking, 
just  as  any  other  laundry  list  accompanies  the  bundle.  When  the  laundry  work 
for  that  department  of  the  hospital  is  completed  the  goods  are  counted  by  the 
laundry  again,  checked  from  the  list,  and  both  list  and  goods  are  sent  back  to  the 
linen  rooms  of  the  department,  or  to  the  main  linen  room  of  the  hospital,  if  it  is 
intended  that  all  goods  shall  emanate  from  a  central  point  rather  than  from  the 
auxiliary  linen  rooms  on  the  floors.  The  original  list  that  had  been  returned  to 
the  head  nurse  of  the  department  may  be  used  by  her  as  a  requisition  for  an  equal 
number  of  pieces  of  every  sort  in  the  shape  of  clean  linens.  If  this  system  is  kept 
rigidly  there  need  be  no  loss  of  articles  from  the  wash. 

Upon  the  size  of  the  institution  and  the  amount  of  laundry  work  will  depend 
the  number  of  people  who  will  be  necessary  to  carry  out  this  system  efficiently. 
The  system  itself  will  not  be  worth  while  unless  it  is  to  be  carried  out  with  a  pre- 
cision amounting  to  a  technic. 

For  a  general  hospital  of,  say,  300  beds,  and  that  means  for  about  700  people 
under  the  average  conditions,  there  should  be  about  four  linen  collectors  and  dis- 
tributors. These  men  will  work  in  pairs.  There  must  be  two  additional  men  in 
the  counting-room,  and  to  oversee  this  force  there  should  be  one  head  linen  man, 
whose  duty  it  should  be  to  see  that  things  are  kept  moving,  and  that  the  men  under 
him  shall  transact  their  business  in  a  prompt  and  workmanlike  manner.  He  will 
also  find  time  to  trace  lost  articles. 

The  Equipment. — The  character  of  hospitals  differs  so  greatly  that  the  equip- 
ment necessary  for  the  laundry  can  be  treated  only  in  a  general  way.  The  remain- 
der of  this  article  will  more  directly  concern  the  machinery  required  and  its  instal- 
lation from  the  standpoint  of  the  architect.  By  machinery  is,  of  course,  understood 
such  as  will  do  the  requisite  work  with  the  fewest  possible  employees,  thus  elimi- 
nating needless  expense  for  labor.  The  number  of  these  will  naturally  depend  upon 
the  amount  and  quality  of  work  to  be  done. 

The  laundry's  cleanliness  is  a  vital  part  of  that  of  the  hospital,  and  in  conse- 
quence the  utmost  care  should  be  devoted  to  its  arrangement  and  equipment.  It 
is  wise  in  selecting  the  latter  to  know  exactly  the  capacity  of  each  machine  and  its 
method  of  operation. 

Location. — The  laundry  should,  whenever  possible,  be  located  in  a  separate 
building,  for  it  may  then  have  a  very  high  ceiling,  sloping  toward  skylights,  roof 
ventilation,  and  windows  on  all  sides,  so  that  perfect  ventilation  and  good  daylight 
illumination  will  result  without  a  spreading  of  the  odors  through  the  hospital 
building. 

The  laundry,  if  by  necessity  located  in  the  hospital,  should  be  at  least  11  or 
12  feet  high,  and  have  not  less  than  two  large  vent  shafts  extending  above  the  roof 
of  the  hospital,  one  to  remove  the  air  from  the  drying  room,  the  other  from  the 
laundry  proper;  fans  to  positively  move  the  air  are  a  practical  necessity,  as  are  also 
suitable  fresh-air  inlets. 

The  Floor. — The  floor  should  be  built  of  concrete,  with  a  water-proofed  cement 
surface,  particularly  that  part  where  the  washing  is  done.  There  should  be  a  gen- 
eral gutter  built  in  as  part  of  the  floor.  This  gutter,  which  should  have  an  outlet 
of  at  least  4  inches,  should  be  built  directly  under  the  washers  and  tubs  (Fig.  201). 

Drains. — Iron  pipes  laid  in  the  concrete  floor  when  the  latter  is  built  should 
run  into  the  gutter  from  all  points  where  there  may  be  water.  A  screen  should  be 
placed  on  the  sewer  outlet.     This  will  prevent  the  pipe  from  clogging  up  with  lint. 


TIIK    INSTITUTION'    LAUNDRY 


615 


All  the  washing  machines  should  drain  into  the  gutter.  If  connected  directly 
with  the  sewer,  articles  not  easily  removed  might  get  into  the  pipes.  This  precau- 
tion does  not  apply  elsewhere  than  in  the  laundry. 

The  amount  of  water  used  or  the  number  of  washers  will  regulate  the  gutter's 
depth  and  width.  There  should  be  a  slope  to  the  floor  of  J  inch  to  the  foot. 
In  this  way  all  the  water  will  run  off  into  the  gutter  and  the  floor  can  be  easily 
flushed  and  cleaned.  A  sewer-trap  connection  should  be  made  at  the  low  point 
in  the  gutter.  If  it  is  thought  that  at  some  future  time  the  washing  equipment 
would  necessarily  be  enlarged  and  more  machines  added,  it  is  quite  advisable 
to  install  an  additional,  gutter  in  which  these  machines  could  be  set  at  a  later  date. 
After  the  gutter  is  constructed  in  the  floor,  heavy  brown  paper  can  be  laid  in  the 
same,  and  the  depression  of  the  gutter  again  filled  with  solid  concrete,  making  the 
floor  level.  At  any  time  it  might  be  necessary  to  use  this  gutter,  that  part  of  the 
concrete  above  the  paper  can  be  easily  broken  out.  This  can  be  arranged  for  at  the 
time  the  floor  is  being  put  in  at  about  10  per  cent,  of  the  cost  of  what  it  would  be 
to  do  so  at  a  later  date. 

Steam. — A  suitable  steam  supply  is  the  first  requisite  in  conducting  the  laundry 
economically.  The  boiler  should  have  a  high  pressure  of  at  least  60  pounds,  though 
not  over  100  pounds  will  be  required.     This  steam  is  not  for  heating  water,  but  for 


Fig.  201. — Section  through  laundry  gutter. 


heating  working  surfaces.  When  one  boiler  is  expected  to  supply  steam  for  the 
entire  hospital  it  should  be  so  connected  to  the  laundry,  either  direct  or  through 
proper  reducing-pressure  valves,  to  obtain  this  required  pressure. 

Ironers  and  dry  rooms  are  among  the  laundry  machines  requiring  high  press- 
ure, and  their  capacities  vary  in  proportion  to  the  steam  pressure.  Locate  the 
boiler  room  as  near  the  laundry  as  possible,  but  never  in  the  same  room.  An 
arrangement  frequently  acceptable  is  an  independent  power  plant,  with  the 
laundry  on  the  floor  above  the  boiler  room. 

Water. — The  laundry  will  require  a  generous  supply  of  both  hot  and  cold  water. 
This  should  be  furnished  through  galvanized  iron  pipes,  at  least  1  inch  and  pre- 
ferably U  to  3  inches  in  diameter,  depending  upon  the  number  and  size  of  wash- 
ing machines.  Hot  water  for  the  laundry  should  be  supplied  either  from  a  water- 
heating  tank  of  ample  size  specially  provided  for  the  laundry  or  from  the  hot-water 
tank  which  supplies  the  institution. 

Power. — Direct  connected  motors  on  each  machine,  excepting  washer-  and 
extractors,  should  be  used  where  possible,  as  the  power  is  used  only  when  the 
machine  is  in  operation,  other  advantages  of  this  method  are  the  ease  of  opera- 
tion, absence  of  noise  and  dirt  inseparable  from  the  use  of  belts  and  the  danger 
attending  their  use,  and  the  ease  and  quickness  with  which  the  machines  can  be 


616  OPERATION    OF   THE    HOSPITAL 

put  into  service.  The  opinion  that  it  is  more  economic  to  run  a  laundry  by  steam 
power  than  by  individual  motor  drives  may  be  borne  out  in  the  case  of  laundries 
operated  alone  or  by  their  own  separate  power  plants,  but  where  a  laundry  is 
operated  in  connection  with  a  hospital  the  steam  supply  and  electric  current 
for  motors  are  usually  available  from  the  hospital  plant  at  a  lower  cost  than  could 
be  met  by  a  steam  engine-drive. 

If  each  machine  is  not  individually  motor  connected,  and  motor  power  is  used 
for  operating  lineshafts  from  which  they  are  belted,  it  is  advisable  that  the  equip- 
ment be  divided  into  groups,  arranged  so  that  should  trouble  occur  with  one  or 
more  motors  there  would  still  be  sufficient  machines  to  permit  of  getting  out 
the  necessary  work  until  the  defective  motors  could  be  repaired  or  replaced;  that 
is  to  say,  one  shaft  and  one  motor  would  serve,  say,  one  or  two  washers  and  one 
extractor,  and  another  motor  and  shaft  would  serve  to  move  another  unit,  so  that 
a  minimum  of  work  could  be  turned  out  when  the  plant  was  running  light. 

While  a  single  motor  of  sufficient  size  can  be  employed  to  operate  the  entire 
equipment,  the  power  required  to  operate  the  power  transmission  machinery 
must  then  be  used  constantly  even  with  a  minimum  load,  as  would  happen  with 
only  part  of  the  machines  in  use. 

Laundry  machinery  manufacturers  are  constantly  striving  to  perfect  indi- 
vidual motor  drives  for  each  machine,  but  the  present-day  progress  does  not  war- 
rant the  recommendation  of  attaching  individual  motors  on  each  machine,  for  the 
reason  that  the  constant  reversing  of  the  motor  is  required,  and,  owing  to  the 
extreme  overload  at  the  reversing  moment,  the  life  of  the  motor  is  greatly  shortened, 
to  say  nothing  of  the  troubles  to  be  had  with  constant  repairs  of  the  reversing 
mechanism. 

If  belt  drive  is  employed,  only  the  best  double  leather  belting  should  be  used 
in  the  wash-room,  as  the  belts  are  subject  to  unusual  strain  when  the  washing 
machines  are  in  operation.  They  are  being  shifted  constantly  from  one  pulley  to 
another  and  the  wash-room  is  always  damp.  Under  such  conditions  inferior  belting 
would  rapidly  become  worthless.  Special  pains  should  be  taken  when  power  comes 
from  a  belt  drive  to  avoid  noise  or  vibration.  Protect  the  dangerous  belts  by 
shields. 

MACHINERY 

Sterilizer. — The  hospital  laundry  may  have  a  sterilizing  and  disinfecting 
machine,  unless  this  important  service  is  performed  at  some  other  locality.  As 
a  matter  of  fact,  it  is  highly  dangerous  to  venture  into  the  laundry  precincts  with 
infected  goods,  and  they  should  be  safely  sterilized  before  being  brought  in.  How- 
ever, the  laundry  machinery  people  make  and  sell  such  a  mechanism.  These 
machines  are  built  with  a  steam  chamber,  whose  steel  inner  and  outer  shells  form 
a  steam  jacket.  The  doors,  which  are  at  both  ends,  are  fitted  to  close  the  cast- 
iron  ends.  The  machine  should  be  so  placed  that  one  end  is  in  the  soiled  linen  room 
and  the  other  in  the  laundry.  In  this  way  all  the  goods  must  pass  through  the 
machine  from  the  soiled  linen  room  and  be  disinfected  before  they  reach  the  laundry. 
The  door  that  opens  into  the  laundry  is  closed  and  the  goods  to  be  disinfected  are 
placed  in  a  wire  basket.  This  is  pushed  into  the  machine,  the  door  on  the  soiled 
linen  side  closed,  and  steam  turned  into  the  jacket.  The  sterilizer  may  be  so 
equipped  that  both  doors  cannot  be  opened  at  the  same  time.  The  chamber  be- 
comes a  drying  oven,  as  the  jacket  is  filled  with  steam  during  the  whole  process. 
By  this  process  the  goods  in  the  machine  are  exposed  to  a  high  temperature  before 
steam  is  introduced  into  the  inner  chamber  and  thoroughly  dried  after  the  steam 


THE    INSTITUTION    LAUNDRY  017 

has  been  exhausted.  A  vacuum  of  15  to  20  inches  is  produced  before  the  introduc- 
tion of  steam  to  the  inner  chamber,  a  vacuum  pump  being  supplied  with  the 
sterilizer  for  this  purpose. 

Sterilizing  Washer. — This  machine  is  built  entirely  of  metal;  from  it  vent  pipes 
run  to  an  exhaust  fan  or  ventilating  shaft;  the  door  is  fastened  securely  with  thumb, 
screws  after  the  goods  have  been  placed  in  the  machine  and  steam  turned  on.  The 
goods  are  then  washed  in  the  usual  way. 

Washers. — Washing  machines  are  of  numerous  types,  some  being  built  entirely 
of  wood;  some  of  wood,  except  the  outer  shell  heads,  which  are  of  iron;  and  some 
constructed  entirely  of  metal  and  of  brass.  Washers  for  hospital  laundries  should 
l>c  built  cither  of  brass  or  with  brass  cylinders  and  galvanized  iron  shells,  as  these 
are  the  most  sanitary,  and  will  best  stand  the  hard  usage  necessitated  by  the  work. 

As  the  goods  are  injured  materially  by  live  steam  blowing  directly  into  the 
linen  and  separating  the  fibers,  every  washer  should  be  provided  with  some  sort  of 
steam  syphon  or  steam  distributing  piping.  To  prevent  the  contents  of  the  washer 
from  becoming  seriously  tangled  and  torn,  the  reversing  movement  necessary  in  all 
washing  machines  must  operate  smoothly  and  uniformly  in  both  directions.  It  is 
desirable  that  the  washers  be  in  small  units  to  allow  different  classes  of  goods  to  be 
washed  separately. 

Extractor. — This  extracts  or  removes  the  water  by  centrifugal  force  from  the 
goods  after  the  washing  process.  The  goods  are  placed  in  a  copper  basket,  built 
on  a  vertical  steel  shaft,  at  the  bottom  of  which  is  the  driving  pulley.  The  basket  is 
perforated  and  reinforced  by  steel  hoops.  The  extractor  travels  at  such  a  high 
speed  that  the  best  obtainable  materials  shoidd  be  secured  to  guarantee  safety. 
The  best  extractors  are  provided  with  heavy  cast-iron  outer  casings  or  housings, 
this  being  one  complete  casting,  no  parts  bolted  together,  which  would  require 
constant  looking  after  to  be  sure  that  a  serious  accident  would  not  occur.  Balanc- 
ing rubber  springs  serve  to  hold  the  curb  or  basket  centrally,  and  rubber  safety 
bumpers  are  provided  to  prevent  the  basket  striking  the  shell  if  loaded  unevenly. 
The  extractor  should  be  provided  with  an  automatic  safety  cover,  of  a  type  that 
would  prevent  the  machine  being  started  until  the  cover  is  closed,  and  again  pre- 
vent the  cover  being  opened  until  the  machine  has  been  brought  to  a  full  stop. 

Soap  Tank. — A  galvanized  iron  soap  tank  is  needed  to  saponify  to  a  liquid  the 
chip  soap  generally  used.  This  is  needed,  whether  the  hospital  purchases  its  soap 
ready  made  or  makes  it  from  tallow  and  soap  stock.  This  tank  should  be  cylin- 
dric  and  have  a  circular  brass  steam  coil  at  the  bottom,  capped  on  the  end,  and  hav- 
ing small  perforations  about  3  inches  apart  throughout  its  extent  to  allow  the  steam 
to  reach  all  parts  of  the  tank.  The  tank  should  have  a  water  supply  and  steam 
and  water  connections  arranged  for  quick  removal  at  such  times  as  the  tank  needs 
cleaning.     Laundry  soaps  are  discussed  at  length  under  the  section  on  Soaps. 

Wash-tubs. — Every  hospital  should  have  stone  or  porcelain  wash-tubs  of  not. 
more  than  three  sections  each,  furnished  with  hot  and  cold  water,  and  one  with  a 
perforated  brass  steam  pipe  (similar  to  that  in  the  soap  tank)  to  boil  water.  This 
steam  pipe  should  be  connected  with  a  swinging  joint  above  the  tub,  so  that  it  may 
readily  be  lifted  up  out  of  the  tub. 

Starch  Cookers.-  Starch  is  always  needed,  even  in  the  smallest  hospital,  and 
some  provision  must  be  made  for  its  preparation.  A  steam  pipe,  so  arranged  that 
it  can  be  put  into  a  pail  or  tub,  is  sometimes  used,  but  it  is  not  to  be  recommended. 
The  chief  objection  to  this  method  is  the  waste,  as  all  unused  starch  made  in  this 
way  has  generally  to  be  thrown  away.  The  use  of  a  starch  cooker  is  the  true  eco- 
nomic method.     This  appliance  is  preferably  made  with  a  galvanized  iron  outer 


618  OPERATION    OF   THE    HOSPITAL 

casing  and  a  copper  lining;  between  these  is  heat-retaining  material  which  keeps  the 
starch  hot  for  a  long  time.  This  cooker  should  have  an  automatic  cover,  a  perfor- 
ated steam  coil,  and  a  condensation  trap  or  steam  separator  to  separate  the  con- 
densed entrained  water  from  the  steam,  so  that  only  the  latter  enters  the  starch. 
In  such  a  cooker  enough  starch  can  generally  be  prepared  and  held  for  a  week's  use 
without  danger  of  spoiling. 

Starching  Machines. — In  most  cases  the  starched  work,  such  as  the  nurses' 
collars  and  cuffs,  can  be  clone  by  hand.  Where  machines  are  in  use  the  dip  wheel, 
as  it  is  commonly  known,  is  most  frequently  employed  for  starching  collars  and 
cuffs.  When  there  is  a  large  amount  of  such  work  it  is  advisable  to  install  a  collar 
and  cuff  starcher,  a  machine  that  starches  the  pieces  completely  at  a  single  passage. 

Dry-rooms. — Dry-rooms  for  hospital  use  are  built  either  of  metal  or  of  wood, 
with  a  lining  of  asbestos  and  heavy  tin.  They  are  practically  fireproof,  easily 
cleaned,  and  easily  kept  clean.  In  the  sizes  usually  called  for  in  hospital  laundries 
the  dry-rooms  are  constructed  in  sections  or  compartments  to  contain  clothes  dry- 
ing racks  made  up  as  trucks.  The  trucks,  having  casters,  run  on  the  floor,  and  can 
be  moved  to  any  part  of  the  laundry.  The  heat  is  furnished  by  steam  coils  placed 
vertically,  one  at  each  side  and  others  between  the  sections.  These  almost  sur- 
round the  trucks  on  which  the  goods  are  hung  during  the  drying  process.  Dry- 
rooms,  holding  two  or  three  trucks,  suffice  for  moderate-sized  hospitals,  and  addi- 
tional sections  and  trucks  can  be  added  as  the  requirements  increase.  Usually  one 
truck  is  furnished  in  excess  of  the  dry-room  capacity.  This  can  be  unloaded  and 
reloaded  while  the  others  are  in  the  dry-room.  Another  feature  of  the  dry-rooms 
is  a  circulating  fan  at  the  top.  This  circulates  the  air  in  the  dry-rooms,  rendering 
the  drying  more  rapid  and  uniform,  and  forces  the  moist  air  through  a  ventilating 
pipe  which  should  be  supplied.  A  dry-room,  under  ordinary  conditions,  with  80 
pounds  steam  pressure  should  dry  a  load  in  thirty  minutes.  There  are  dry-rooms 
built  which  have  the  clothes  draws  suspended  from  overhead  tracks  or  beams,  but 
necessarily  they  are  not  so  conveniently  operated,  as  the  clothes  must  be  brought 
to  the  draws  in  front  of  the  dry-rooms.  In  a  number  of  large  institutions  the  con- 
tinuous "conveyer"  type  is  in  use.  In  this  the  articles  placed  on  hangers  are  car- 
ried on  an  endless  chain  on  a  winding  course  within  the  heated  cabinet  at  a  speed 
so  adjusted  that  they  are  thoroughly  dried  before  emerging. 

The  dry-room  steam  coils  should  be  provided  with  a  good  steam  trap  to  permit 
the  water  of  condensation  to  escape  and  hold  back  the  dry  steam.  This  condensed 
water  should  be  returned  by  being  piped  back  to  the  hot-water  tank. 

Dampeners. — Different  goods  require  more  or  less  dampening  before  passing 
to  the  ironers.  Various  machines  have  been  designed  for  this,  operated  either  by 
power  or  hand  pressure.  In  some  the  dampening  is  accomplished  by  a  fine  spray, 
while  in  others  the  articles  are  passed  through  rubber  rolls  running  in  troughs 
where  water  is  uniformly  supplied.     The  former  method  is  preferable. 

Ironers. — The  ironer  is  one  of  the  most  important  machines  in  the  equipment 
of  the  hospital  laundry.  To-day  flat  work  is  never  dried  in  the  dry-rooms,  but  is 
taken  to  the  ironer  direct  from  the  extractor.  High  pressure  is  absolutely  necessary 
to  secure  results.  The  cylinder  type  of  machine  is  largely  used  for  hospital  work, 
the  size  of  the  cylinder  being  determined  by  the  amount  of  work.  These  ironers 
are  built  with  cylinders  varying  between  16  and  48  inches  in  diameter  and  from  48 
to  120  inches  in  length.  Auxiliary  rolls,  covered  with  wool  covering,  between 
which  the  goods  which  are  being  dried  and  ironed  pass,  are  placed  at  various  angles 
around  these  cylinders.  This  type  of  ironer,  with  its  apron  attachments,  carries 
the  goods  around  the  cylinder  to  the  side  opposite  from  which  they  are  fed,  where 


THE    [NSTIT1  TION    LAI  NDin 


lil'.l 


they  are  received  and  folded.  The  cylinder  type  requires  less  space  for  its  installa- 
tion. Another  type  of  ironer  is  the  chesl  type,  where  as  many  chests  can  be  boughl 
as  the  amount  of  work  warrants.  As  the  work  increases  other  chest-  can  he  pur- 
chased and  combined  with  those  already  in  use.  This  type  is  especially  useful  in 
smaller  laundries  or  where  an  increase  in  the  work  is  probable. 

The  cylinder  type  of  machine  is  much  preferred,  for  the  reason  that  the  goods 
in  being  ironed  are  carried  along  by  the  travel  of  the  cylinder  under  padded  rolls 
that  also  travel  with  the  cylinder;  consequently,  the  goods  are  not  subjected  to  the 
strain  and  wear  that  they  would  be  subjected  to  while  traveling  through  the  chest 
type  of  machine,  for  in  the  latter  case  the  chests  are  concave  in  shape  and  stationary, 
and  the  goods  are  carried  over  these  chests  by  rolls  and  strings  from  roll  to  roll. 
It  is  easily  demonstrated  that  a  wet  newspaper  can  lie  ironed  without  fear  of  tearing 
on  the  cylinder  type  of  machine,  while  on  the  chest  machine  this  would  be  an 
impossibility,  which  would  readily  show  the  merits  of  the  cylinder  type  of  machine. 
The  custom  laundries  are  favorable  to  the  chest  type  of  machine,  owing  to  their 
somewhat  larger  capacity,  and  the  fact  that  cheap  hair  covering  can  be  used  on 
them,  but  it  must  be  remembered  that  the  custom  laundries  are  not  handling  their 
own  goods,  and  they  have  no  interest  in  how  long  the  goods  they  are  laundering 
will  last. 

No  ironer  should  he  purchased  which  does  not  have  automatic  safety  devices 
at  the  feed  side.  These  devices  promptly  bring  the  machine  to  a  stop,  and  thus 
protect  the  operators  from  being  caught  while  feeding  the  ironer,  if  accidentally 
they  approach  the  rollers  too  closely.  The  automatic  feed  makes  it  possible  to 
feed  the  goods  straight  and  without  turned  edges.  The  ironer  should  be  provided 
with  a  steam  trap  for  the  same  purpose  as  the  dry-room. 

Body  Ironer. — This  machine  was  used  originally  for  ironing  the  bodies  of  shirts. 
It  is  now  also  employed  to  iron  underwear,  aprons,  coats,  skirts,  stockings: almost 
any  garment  in  fact.  It  is  built  on  the  same  principle  of  operation  as  the  ironer. 
I >ut  has  only  two  short  rolls  working  free  at  one  end.  Between  its  rolls,  one  heated 
by  gas  or  electricity,  the  articles  to  be  ironed  are  placed.  The  rolls  are  then  pressed 
tightly  together  by  means  of  a  foot  lever  and  revolved.  One  operator  with  a  body 
ironer  can  easily  do  the  work  of  four  hand-ironers.  Some  very  small  hospitals  use 
it  in  place  of  a  flat-work  ironer. 

Ironing  Boards. — Every  hospital  and  laundry  should  have  two  or  more  iron- 
ing boards  for  hand  work.  These  are  built  on  iron  bases  and  are  supplied  with 
swinging  sleeve  boards. 

Irons. — Cleanliness  and  economy  advise  the  use  of  electric-heated  flat  irons, 
though  there  are  grave  objections  to  them  as  stated  heretofore.  If  ordinary  irons 
are  used,  gas  sad-iron  heaters  should  be  furnished  with  the  ironing  hoards. 

Rotary  Tumbler.— If  the  hospital  is  of  such  a  size  that  5000  pieces  or  over  must 

be  laundered  each  day  a  tumbler  should  be  put  in.     This  machine  take-  th<  g Is 

from  the  extractor  in  a  solid  mass  and  -hakes  them  up,  removing  all  lint.    Through 

it-  use  much  time  is  saved  that  otherwise  would  be  spent  in  shaking  out  the  g Is 

before  feeding  them  into  the  ironer.  Another  feature  sometimes  installed  is  the 
dry-room  tumbler,  a  machine  combining  the  principles  of  both.  The  goods, 
when  taken  from  the  extractor,  are  placed  in  a  cylinder  or  compartment,  where  they 
are  revolved  in  the  same  way  as  in  a  washing  machine  while  exposed  to  a  continual 
current  of  highly  heated  air.  Unstarched  goods  thus  dried  do  not  require  to  be 
ironed.  Starched  goods,  like  nurses'  dresses,  can  be  kept  in  this  machine  until 
about   nine-tenths  dry  and  then  passed  to  the  ironer.  eliminating  the  nece— it\    of 

dampening.     A  greater  saving  is  to  be  had  with  the  use  of  this  machine  than  with 


620  OPERATION    OF   THE    HOSPITAL 

the  regulation  dry-room,  for  in  the  former  help  is  required  to  hand  the  goods  up 
and  to  take  them  down,  while  the  washman  or  wringer-man  can  do  this  work 
with  a  dry-room  tumbler.  There  is  no  form  of  drying  blankets,  bath  towels,  etc., 
where  the  work  will  be  as  soft  and  as  beautifully  finished  as  when  dried  in  a  dry- 
room  tumbler.  With  it  the  feather  pillow  can  be  washed  the  same  as  a  sheet,  ex- 
tracted in  the  same  manner,  and  then  placed  in  the  dry-room  tumbler  and  thor- 
oughly dried,  wrhich  gives  renewed  life  to  the  pillow7,  making  it  sanitary  and 
sweet  smelling. 

Collar  and  Cuff  Ironer. — If  the  hospital  has  more  collars  and  cuffs  than  a  hand 
ironer  can  dispose  of  in  an  hour  a  small  collar  and  cuff  ironer  should  be  installed. 
This  machine  has  a  heated  and  padded  roll,  through  which  the  pieces  receive  much 
more  pressure  than  when  ironed  by  hand  or  in  a  body  ironer. 

A  curtain  stretcher  is  another  laundry  requisite.  A  good  type  is  a  frame  made  of 
galvanized  iron  pipe  with  adjustable  corner  sockets.  Others  are  made  in  the  form 
of  curtain  trucks  which  can  be  run  into  dry-rooms. 

Insulation. — Cover  all  steam  pipes  with  high-grade  insulation.  In  every  well- 
equipped  public  laundry  are  numerous  serviceable  and  efficient  machines,  which 
might  be  installed  to  suit  various  special  requirements  with  profit  and  advantage 
in  a  hospital  plant.  Those  mentioned,  however,  practically  cover  the  requirements 
in  a  manner  to  give  satisfactory  operation. 

LAUNDRY  POWER 

It  appears  practically  impossible  to  give  figures  for  the  required  horsepower 
and  current  which  would  be  universally  applicable  and  without  danger  of  having 
them  misapplied. 

The  following  will  serve  as  a  guide,  but  must  be  verified  by  an  expert  previous 
to  making  use  of  them  in  individual  cases: 

Power  in  Laundry: 

One  28-inch  extractor  requires 2  H.  P. 

One  36-  by  62-inch  washer  requires 3      " 

Two  36-  by  62-inch  washers  require 5      " 

Three  36-  by  62-inch  washers  require 1\    " 

One  36-  by  48-inch  washer  requires 2      " 

Speed  of  extractor,  900  to  1400  RPM,  depending  on  the  size  of  the  basket. 

Flat  work  ironer 1-2J  H.  P. 

Collar  and  cuff  ironer J-l  H.  P. 

Body  ironers |H.  P. 

Shirt  ironers i      " 

Handkerchief  ironer i      " 

Band  ironer i      " 

Starchers  for  collars,  shirts,  etc I      " 

Electric  Heated  Laundry  Machinery: 

5|-pound  irons  consume 600  watts  per  hour. 

Shirt  ironers  consume 1100-2200  watts  per  hour. 

Body  ironers  consume 2200-3520  " 

Band  ironers  consume 550-  650 

Collar  ironers  consume 650-2500  "           " 

Sleeve  ironers  consume 1100-1600  "           " 

Linen  Collectors. — A  very  convenient  form  of  linen  collector  is  shown  in  Fig. 
202.  The  stand  is  made  of  wrought  iron,  and  consists  merely  of  two  rings,  to  which 
three  upright  pieces  are  riveted.  It  will  be  noticed  that  these  uprights  are  not  equi- 
distant from  each  other,  and  that  one-half  of  the  stand  is  free  for  the  purpose  of 


THE    INSTITUTION    LAUNDRY 


621 


drawing  out  the  bagful  of  linen.  The  stand  is  very  firmly  fixed  on  turned  feet,  or, 
if  preferred,  casters  can  be  used.  As  a  rule,  this  stand  will  not  be  moved  about 
much  and  casters  will  hardly  be  justified.  The  bug  is  made  of  rather  heavy  canvas, 
but  not  too  heavy  to  be  washed  easily.  It  has  a  bucket-shaped  bottom  and  draw- 
string in  the  top.  There  are  brass  eyes  at  intervals  in  the  bag  and  hooks  on  the 
inside  upper  rim  of  the  stand.  It  is  very  easy  to  release  the  bag  from  the  hooks 
and  to  draw  it  out  through  the  large  opening  in  the  stand.  The  linen  is  carried  to 
the  laundry  and  to  the  counting-room  in  these  bags,  and  the  bags  are  washed  and 
returned  to  be  used  as  a  receptacle  again.     If  a  linen  chute  is  used  in  the  building, 


Fie.  202. — Linen  collector. 

these  linen  bags  prevent  very  much  tearing  of  the  linen,  and  make  it  unnecessary 
for  the  help  to  tic  up  the  soiled  linen  in  the  sheets  or  bedspreads,  which  they  are 
very  much  inclined  to  do. 


EQUIPMENT  OF  LINEN  ROOMS 

Before  we  can  equip  the  linen  rooms  and  their  appurtenances  it  will  be  profitable 
to  trace  the  linens  of  the  institution  from  their  source  on  the  shelves  back  again  to 
the  same  resting  place,  and  to  follow  them  through  the  process  of  becoming  -oiled 
and  again  becoming  clean,  and  the  various  steps  of  their  travel,  as  shown  in  the 
laundry  travel  illustration  heretofore. 

In  the  first  place,  the  linens  arc  taken  from  the  linen  room  by  or  at  the  instance 
of  the  senior  nurses  at  the  heads  of  the  departments,  on  requisitions  signed  by  the 
superintendent  of  the  training-school  or  bead  nurse.     The   physical  operation  of 


622 


OPERATION    OF   THE    HOSPITAL 


taking  them  is  generally  performed  by  the  orderly,  who  takes  the  requisitions  to  the 
linen  room  keeper  and  receives  the  linens  in  return.  The  linens  are  then  taken  to 
the  auxiliary  linen  rooms  off  the  wards,  or  somewhere  on  the  corridors  of  the  private 
pavilion.  These  auxiliary  linen  rooms  and  the  key  are  kept  by  the  head  nurse, 
who  distributes  the  linens  at  certain  times  to  the  nurses  in  the  various  departments 
of  her  territory.  The  soiled  linens  from  the  beds  are  then  thrown  into  the  soiled 
linen  receptacles  and  the  clean  linens  put  on  the  beds.  These  soiled  linens  are  then 
gathered  up  by  linen  collectors,  employed  for  the  purpose,  or  by  the  orderlies  on 
the  floors.  Sometimes  these  receptacles  are  taken  directly  to  the  laundry,  either 
by  way  of  laundry  chutes  or  freight  elevators,  and  without  any  counting  or  other 
method  of  segregation.  The  linens  are  then  washed,  and  are  taken  on  the  linen 
trucks  back  to  the  linen  room  and  restored  to  the  shelves.  These  processes  of 
movement  require  certain  equipment,  and  the  simplicity  or  complexity  of  that 
movement  will  depend  a  good  deal  on  the  disposition  of  the  hospital  administration 
to  keep  accurate  accounts  of  its  operations,  the  size  of  the  institution,  and  sim- 


^^^ 


Fig.  203. 


plicity  or  complexity  of  the  units  of  the  hospital.  That  is  to  say,  a  railroad  men's 
hospital  would  require  comparatively  few  units  of  linen,  whereas  a  general  hospital, 
containing  a  maternity,  a  children's,  surgical,  medical,  and  special  departments, 
would  require  a  vast  number  of  different  sorts  of  linen,  and  consequently  the  process 
of  handling  the  linen  would  become  a  very  intricate  one. 

However,  let  us  now  proceed  to  the  equipment  of  a  linen  service  as  though  we 
intended  to  keep  a  strict  account  of  our  linens  and  to  do  the  thing  in  a  methodic, 
workmanlike  sort  of  way.  The  linen  room  is  a  simple  affair,  as  shown  in  Fig.  203, 
composed  of  a  single  large  room  with  a  high  ceiling,  with  shelves  on  all  sides,  except- 
ing where  the  doors  and  windows  are.  These  shelves  must  go  up  so  high  in  the 
room  that  a  substantial  stepladder  will  have  to  be  used  hah  the  time  to  get  at  the 
compartments  desired.  Unless  the  shelves  go  clear  to  the  top  of  the  room  the 
top  should  be  beveled  with  a  steep  pitch,  so  that  dirt  can  be  seen  on  the  top. 
Drawers  should  never  be  used,  and  the  only  particular  point  about  the  shelving  is 
the  doors,  and  these  doors  should  be  hinged  at  the  bottom  and  fastened  at  the  top, 


THE   INSTITUTION    LAUNDRY  623 

held  with  a  chain  on  each  side,  so  that  when  they  are  opened  they  form  a  flat  shelf 
for  the  handling  of  the  pieces  as  they  are  drawn  out  of  the  shelving.  The  catch  to 
this  door  is  the  most  important  thing  about  it,  and  most  catches  are  cheap,  poorly 
made,  and  soon  get  out  of  order.     There  is  no  particular  kind  that  is  best. 

The  linen  rooms  ought  to  have  two  doors,  one  leading  directly  into  the  body 
fit'  the  room  and  the  other  fronting  up  against  a  counter,  as  shown  in  the  cut,  since 
it  is  not  desired  that  the  nurses  and  orderlies  who  are  requisitioning  linen  shall 
come  into  the  room  itself. 

Since  the  hours  for  requisitioning  linen  are  short,  all  of  the  materials  for  work 
in  the  linen  room  ought  to  be  in  the  room  itself,  so  that  all  of  the  people  who  are 
working  there  can  make  the  most  of  their  time.  When  there  is  no  distributing 
they  can  be  mending  or  sorting. 

Generally  speaking,  the  linen  room  of  a  large  institution  will  be  presided  over 
by  a  head  woman,  and  she  will  usually  have  at  least  one  paid  assistant.  In  most 
institutions  the  probationers  from  the  nursing  department  do  the  greater  part  of 
the  mending  and  the  making  of  new  things,  so  that  it  will  be  necessary  for  the  linen 
room  to  be  equipped  for  running  the  sewing  machines,  and  this  can  be  done  very 
nicely,  as  shown  in  the  cut.  The  day  is  past  when  women,  whether  they  be  paid 
linen  menders  or  workers,  or  whether  they  be  probationers  in  a  training-school,  can 
be  expected  to  work  a  foot-pedal  sewing  machine  all  day.  That  operation  is  one 
of  the  hardest  tasks  that  a  woman  ever  has  to  do,  and  is  almost  certain  sooner  or 
later  to  disturb  the  functions  of  her  genito-urinary  and  gastro-intestinal  viscera. 

A  line  of  shafting,  belted  to  the  running  gear  of  the  individual  machine,  is  entirely 
too  intricate  a  mechanism  to  be  operated  easily  by  women.  There  is  too  much 
mechanics  about  it ;  therefore,  the  correct  way  is  to  operate  each  machine  by  its 
own  individual  motor  with  belt-drive  to  the  machine  mechanism.  In  this  way  the 
pulleys  and  belting  can  be  made  of  proper  size  and  length  to  accommodate  any 
desired  speed  in  the  machines,  and  it  is  far  preferable  that  these  motors  have  at  least 
three  speeds,  attained  preferably  by  knee  action. 

This  is  practically  all  there  is  to  the  main  linen  room,  which  must,  of  course, 
In'  will  lighted  and  well  ventilated. 


AUXILIARY  LINEN  ROOMS 

The  auxiliary  linen  rooms  of  the  institution  are  of  little  importance  so  far  as 
their  internal  arrangements  are  concerned,  but  of  immense  importance  as  to  their 
location.  Ten  yards  too  far  one  way  or  the  other  for  the  auxiliary  linen  rooms  will 
mean  hundreds  of  yards  of  walking  per  day  for  the  nurses,  and  this  means  time  and 
labor  that  in  the  course  of  the  year  are  well  worth  saving,  so  that  great  care  must 
be  taken  to  locate  these  auxiliary  linen  rooms  at  the  most  central  points  nearest 
to  those  centers  where  the  vast  bulk  of  the  linen  is  to  be  used. 

Generally  speaking,  these  rooms  cannot  be  lighted  from  a  window,  and,  there- 
fore, they  should  have  one  or  more  electric  drop  lights  operated  by  means  of  a  door 
switch,  so  that  the  lamps  will  lie  lighted  when  the  door  opens  and  put  out  when  the 
door  is  closed.  The  room  itself  should  be  long  and  narrow,  with  shelving  on  one  or 
both  sides,  the  shelving  built  precisely  as  the  shelving  in  the  main  linen  room,  with 
drop  doors  that  can  be  used  as  tables  on  which  to  work  with  the  linen.  Nothing 
should  be  kept  in  these  auxiliary  linen  rooms  excepting  the  limns,  and  by  no  means 
should  the  blankets  be  kept  there,  because  necessarily  these  rooms  will  be  without 
ventilation,  or  practically  so,  and  blankets  should  never  be  kept  except  in  a  well- 
lighted,  well-ventilated,  dry  place. 


624  OPERATION    OF    THE    HOSPITAL 


SOILED  LINEN  COUNTING-ROOM 


If  any  sort  of  reckoning  is  to  be  kept  on  the  linens  in  the  institution  there  must 
be  a  central  counting-room,  through  which  all  soiled  linens  must  go  on  their  way  to 
the  laundry,  and  if  this  work  is  to  be  clone  in  a  methodic,  comprehensive,  efficient 
manner,  this  central  counting-room  for  soiled  linens  is  an  item  of  importance  in  the 
institution.  It  may  be  at  the  foot  of  the  freight  elevator,  if  the  soiled  linens  are 
carried  that  way,  or  it  may  be  at  the  bottom  of  a  chute,  if  the  chute  method  is  em- 
ployed to  get  the  linen  bags  to  the  main  floor.  In  either  case,  the  counting-room 
is  merely  a  large  room  containing  a  considerable  number  of  bins,  on  at  least  three 
sides  of  the  room,  and  with  a  large  central  platform,  about  18  inches  high,  occupy- 
ing most  of  the  balance  of  the  floor  space  in  the  room,  leaving  only  sufficient  floor 
space  for  a  roomy  walk.  The  bags  of  soiled  linen  may  be  dumped  from  the  freight 
elevator  or  chute  into  the  room.  This  whole  equipment  presupposes  that  the 
laundry  is  in  a  building  entirely  separate  and  at  a  distance  from  the  hospital. 

LAUNDRY  CHUTES 

One  of  the  petty  annoyances  of  the  daily  hospital  life  is  the  carting  about  of 
soiled  linens.  Crude  methods  are  in  vogue  in  most  institutions.  Baskets  and  carts, 
and  the  elevator,  passenger  or  freight,  are  the  commonest  means  of  transportation. 
There  are  chutes  extending  from  the  top  of  the  house  to  the  bottom  in  many  hospi- 
tals; some  of  them  made  of  tongue-and-groove  flooring  and  others  of  galvanized 
or  sheet  metal;  usually  they  are  built  inside  the  house,  and  almost  always  they  are 
dirty,  drafty,  ill-smelling  places,  streaked  with  dried  blood  or  worse,  and  are  a 
constant  fire  menace  on  account  of  the  drafts  they  harbor. 

In  some  hospitals  the  chutes  are  rendered  as  mildly  offensive  as  possible  by  the 
use  of  heavy  canvas  laundry  bags,  but  it  is  extremely  difficult  to  enforce  the  use 
of  these  bags  on  the  wards  of  a  hospital  or  on  the  floors  of  a  hotel.  Nurses  in  a 
hospital  almost  refuse  to  use  them,  and  persist  in  tying  the  laundry  in  sheets  and 
throwing  it  into  the  chute;  the  sheet  used  for  the  purpose  is  torn  in  almost  every 
case,  if  not  in  the  chute  itself,  certainly  in  the  further  journey  to  the  laundry  at  the 
hands  of  the  linen  men.  Sometimes  the  nurses  use  pillow  cases  instead  of  laundry 
bags,  as  being  more  convenient  and  more  often  within  reach,  and  the  pillow  case 
is  always  useless  thereafter. 

If  the  ordinary  chute  is  to  be  used,  it  should  be  placed  outside  the  building,  along 
a  tier  of  windows,  easily  accessible,  with  an  opening  at  each  window,  and  with  small 
ventilated  intervals  throughout  the  chute,  the  ventilators  made  so  that  rain  and 
snow  cannot  penetrate;  there  can  be  an  upturn  at  the  bottom  to  break  the  fall  and 
slide  the  bundles  to  a  table  or  platform.  These  outside  chutes  do  not  remain  any 
cleaner  than  those  inside,  but  they  are  not  offensive  and  do  not  encourage  drafts. 
They  can  be  cleaned  occasionally  by  hand,  the  workmen  being  lowered  on  a  pulley 
seat,  steeple-jack  fashion. 

Europe,  and  more  especially  Germany,  is  adopting  a  glass  cylinder  chute  that  is 
a  distinct  advance  over  other  methods  of  transporting  soiled  clothes.  The  chute, 
when  completed,  is  3  feet  in  diameter,  and  extends  from  the  basement  collection 
room  to  a  point  at  the  elevation  of  the  roof,  with  roof  ventilation  and  with 
openings  at  each  floor.  There  are  showers  in  the  top,  with  small  holes  bored  at 
intervals,  and  in  such  manner  that  the  water  will  shoot  outward  to  the  walls  of 
the  chute;  both  hot  and  cold  water  are  used  for  cleaning. 

The  walls  of  the  chute  are  made  of  heavy,  cheap  glass  like  that  used  for  area 
sidewalks,  and  in  semicircular  segments,  3  feet  long  and  a  half -circle  in  shape, 


TIIF.   INSTITUTION    LAUNDRY 


025 


two  of  them  make  a  section  of  chute  3  feet  long,  and  they  are  bound  together  by 
a  special  glass  cement. 

Another  form  of  linen  chute  is  patterned 
after  the  circular  fire  chutes  used  in  con- 
nection with  some  schools  and  asylums, 
with  smooth  spiral  surface  for  sliding  the 
baskets  or  bags.  Still  another  form,  sug- 
gested, if  not  actually  in  use  anywhere,  is 
patterned  after  the  parcel  conveyors  in 
some  of  the  large  department  and  mail- 
order houses.  It  is  an  endless-chain 
arrangement  with  shelves  at  intervals. 
There  is  a  mechanism  by  which  the  chain 
is  automatically  stopped  whenever  one  of 
the  floor  doors  is  opened,  and  when  the 
door  is  closed  the  chain  is  released  to  move 
along.  The  difficulty  with  this  system  is 
that  it  is  very  noisy,  a  matter  of  not  very 
much  moment  in  a  mercantile  house,  but 
vital  in  a  hospital. 

A  newly  devised  laundry  chute,  and 
one  which  promises  to  bring  the  chute 
principle  into  greater  favor,  is  made  by  the 
Pfaudler  Co.,  of  Rochester,  New  York.  It 
was  originally  made  and  is  still  used  for 
beer  vats,  but  has  been  shaped  different  ly 
and  perfected  for  service  as  a  laundry 
chute.  It  is  installed  for  the  first  time  in 
the  new  Sarah  Morris  Hospital  for  Chil- 
dren of  the  Michael  Reese  Hospital. 

It  consists  of  rings  of  iron,  glass  lined 
on  the  inside,  and  is  made  in  sections  or 
rings,  3  or  4  feet  long,  and  of  any  de- 
sired diameter.  The  sections  are  made 
gasketed,  so  that  they  fit  water-tight  one 
against  another,  and  the  chute  can  be 
made  of  any  desired  length  in  that  way. 
The  joints  are  so  perfect  and  the  sections 
fit  so  closely  that  they  arc  waterproof,  and 
can  thus  be  washed  out  at  any  time  with 
hot  or  cold  water  shower  at  the  top. 

The  glass  is  fused  into  the  metal  at  a 
temperature  of  about  2600°  F.  and  does 
not  crack  or  split  off  under  any  variations 
in  temperature.  The  bottom  of  the  chute 
ends  in  a  drain-pipe  with  trap  and  grate, 
so  that  it  is  perfectly  clean  and  sweel  all 
the  time.  At  the  top  there  is  a  shower 
crown  for  hot  and  cold  water  for  cleaning 
purposes.  The  top  of  fche  chute  is  led  to  the  roof,  and  is  covered  with  a  hood, 
figure  2(1 1  shows  some  of  the  details  of  this  chute. 


orcehtin  lined 


tst  metal. 


THE  DESTRUCTION  OF  WASTE 

Modern  practice  will  not  permit  of  any  other  method  of  the  disposal  of  garbage 
and  waste  of  all  kinds  than  its  absolute  destruction  by  fire.  But  there  are  several 
things  to  be  taken  into  consideration  in  connection  with  the  burning  of  waste: 
First,  all  garbage  and  waste  must  be  destroyed  under  conditions  that  will  not  per- 
mit infections  of  any  kind  to  be  scattered  about  the  premises  or  go  into  the  sewage 
system  of  the  institution  or  of  the  community;  second,  it  must  be  destroyed  in 
such  a  way  that  valuable  things,  such  as  silverware,  dishes,  and  cleanable  rubber 
articles,  shall  not  be  thrown  away;  third,  it  must  be  destroyed  under  conditions 
that  will  create  the  least  possible  nuisance  in  the  form  of  odors  and  smoke. 

Let  us  speak  very  briefly,  now,  about  another  disposition  of  certain  parts  of 
the  waste.  Small  hospitals,  in  the  country  or  in  small  cities,  usually  are  importuned 
by  farmers,  either  raisers  of  pigs  or  poultry,  to  give  their  garbage  for  food  purposes. 
There  can  hardly  be  an  objection  to  this,  but  the  institution  must  be  responsible 
to  the  community  in  which  it  exists  for  correct  practice  in  all  things;  therefore,  it 
should  insist  that  waste  food  should  be  taken  away  and  used  under  conditions 
that  are  proper,  considering  the  stock  to  which  it  is  to  be  fed.  A  good  many  swill 
and  slop  collectors  are  in  the  habit  of  getting  around  to  the  tanks  two  or  three  times 
a  week;  in  the  summer  time  this  is  out  of  the  question,  both  from  the  view-point 
of  the  institution,  on  accoimt  of  the  odors  that  emanate  from  decomposing  waste 
and  from  the  standpoint  of  the  stock  to  which  the  waste  is  to  go,  because  decompos- 
ing stuff  is  not  proper  food  for  animals.  Then  again  it  is  highly  necessary,  if  we 
are  to  allow  garbage  collectors  to  take  our  food  waste,  that  there  should  be  some 
means  to  guarantee  the  cleanliness  of  this  waste;  that  is  to  say,  no  possible  infectious 
matter,  such  as  soiled  bandages  or  dressings  or  the  fluids  from  these,  should  be 
allowed  to  get  into  and  contaminate  the  slop  barrels. 

Some  institutions  have  farms  of  their  own  or  are  in  close  relationship  with 
nearby  farmers,  and  their  slops  are  saved  with  almost  as  definite  a  technic  as  any 
other  routine  process  of  the  institution.  There  are  tight  metal  receptacles  for  each 
kind  of  waste,  one  for  cabbage  and  lettuce  leaves,  celery  tops,  potato  peelings,  and 
so  on;  another  for  the  residue  of  the  soup  stocks,  that  is,  the  used  meats  that  are  of 
no  further  use.  Then  there  are  other  receptacles  for  feathers  or  the  intestines  of 
poultry.  And  then  there  are  still  other  receptacles  for  the  combination  wastes 
that  come  from  the  serving  rooms  and  dining  rooms — the  scrapings  of  the  dishes. 

Some  institutions  save  their  feathers,  wash  and  dry  them,  and  make  them  up 
into  pillows,  and  this  is  not  a  difficult  thing  to  do,  provided  there  is  a  rotary  air 
blast  laundry  tumbler  at  hand.  But  it  may  be  very  seriously  questioned  whether 
institution  employees  will  earn  very  much  at  this  kind  of  work .  They  are  not  experts 
at  it,  they  do  it  very  slowly,  and  at  the  end  of  the  year  it  will  probably  be  found  that 
their  time  could  have  been  more  profitably  employed  at  things  in  which  they  were 
more  skilful. 

Both  hogs  and  poultry  are  very  fond  of  the  intestines  of  poultry  and  devour 
them  with  great  relish,  and  when  fresh  and  unfermented  there  seems  to  be  no  reason 
why  this  offal  should  not  be  good  food.     The  contents  of  the  intestines  are  usually 

626 


THE    DESTRUCTION'    OF    WASTE  627 

made  up  of  partially  digested  grain,  and  the  intestines  themselves  contain  about  as 
much  nutriment  as  a  similar  weight  of  any  other  meat;  but  it  may  be  very  seriously 
questioned  whether  either  poultry  or  hogs  will  be  benefited  very  much  by  feeding 
on  intestines  and  their  contents  that  have  laid  in  the  slop  barrel  for  several  days, 
especially  in  warm  weather. 

The  above  specialized  treatment  and  husbandry  of  waste  food  products,  and 
their  profitable  employment  as  food  for  animals,  will  perhaps  appeal  more  to  small 
institutions,  located  in  the  neighborhood  of  a  fanning  community,  than  to  the  large 
metropolitan  hospital,  situated  far  away  from  the  country;  and  most  of  us  will  per- 
haps want  to  destroy  nearly  all  the  waste  that  comes  out  of  the  institution.  Then 
we  ask  ourselves  what  is  the  best  method  for  its  destruction;  naturally,  burning, 
but  in  what  way,  and  can  it  be  done  more  economically  and  effectively  in  one  way 
than  in  another? 

There  are  patent  garbage  incinerators  of  all  sorts,  and  these  may  be  classified 
under  three  heads — first,  the  central  garbage  burner,  located  in  an  outhouse,  to 
which  everything  goes;  second,  a  combination  boiler  and  garbage  destroyer,  for 
small  institutions  in  which  the  garbage  is  made  to  play  its  part  as  a  fuel;  third,  the 
so-called  sanitary  garbage  incinerators,  located  at  different  points  inside  the  insti- 
tution and  connected  to  a  flue. 

The  Sanitary  Garbage  Plant. — There  is  very  much  doubt  whether  anything  is 
more  economic  or  efficient  and  sanitary  than  a  garbage  incinerator,  properly  built 
and  located  in  some  outhouse.  Figure  205  shows  as  simple  and  efficient  a  garbage 
burner  as  can  be  built.  There  are  much  costlier  ones  that  can  be  purchased  out- 
right, and  set  up  inside  a  brick  wall  in  about  the  same  way  that  the  ordinary  home 
basement  furnace  is  set  up  and  bricked  in.  These  purchased  incinerators  cost 
from  81200  to  S2000  each,  and  they  are  not  more  efficient  or  economic  than  the 
home-made  affair  that  costs  in  the  neighborhood  of  S300.  The  illustration  shows 
a  large  central  door  at  the  top,  into  which  all  the  garbage,  including  the  fluids,  is 
thrown.  Inside  this  door  is  a  wrougluVsteel  tube,  open  at  both  ends,  and  having 
a  diameter  of  about  30  inches.  Both  ends  are  open,  one  backing  up  tightly,  and 
scaled  with  fire  clay  against  the  door;  the  other  end  is  left  open,  giving  a  free  exit 
to  the  flue.  This  tube  is  about  5  or  6  feet  long,  or  longer  if  the  amount  of  garbage 
is  sufficient  to  justify  so  large  a  receptacle.  On  either  side,  and  below  this  large 
door,  are  two  smaller  square  ones,  and  these  arc  where  the  fires  are  made.  They  are 
ordinary  grates,  almost  as  long  as  the  tube  above,  and  there  is  free  access  from  each 
to  the  flue  at  the  rear.  Below  these  two  doors  are  two  smaller  ones  for  the  with- 
drawal cf  ashes. 

The  process  of  operation  is  as  follows:  In  the  morning  a  small  coal  fire  is  made 
in  each  grate,  and  for  a  very  large  institution  not  more  than  200  or  300 
pounds  of  coal  need  be  used  in  the  course  of  a  day.  This  first  fire  heats  the  tube 
and  dries  all  the  moisture  out  of  the  garbage  that  has  been  thrown  into  it;  then, 
with  a  shovel  made  for  the  purpose,  the  dried  out  garbage  is  withdrawn  from  the 
tube  and  thrown  into  the  fires.  Then  more  garbage  can  be  thrown  in,  and  so  the 
process  goes  on  throughout  the  day.  It  is  necessary  to  comb  the  garbage  carefully 
to  save  the  valuable  things  thai  have  been  thrown  into  it:  in  some  large  institutions. 
such  as  the  Massachusetts  General  Hospital,  the  garbage  comber  is  a  fixture  in  the 
community— an  old  man,  worn  out  in  service  elsewhere  in  the  institution,  but 
conscientious  and  careful,  and  to  lie  trusted  to  return  the  salvage  to  some  central 
point  designated  for  it-  reception. 

In  the  Michael  Reese  Hospital  an  attempt  is  made  to  locate  the  sources  of  im- 
providence by  numbering  all  the  garbage  cans,  each  having  its  own  location  in 


628 


OPERATION    OF    THE    HOSPITAL 


the  house.  Articles  of  value  of  all  sorts,  including  broken  dishes,  are  wrapped  up 
after  they  have  been  retrieved  and  are  sent  to  the  storerooms,  with  the  number 
of  the  can  from  which  they  came ;  given  a  knowledge  of  the  people  who  are  using  a 
particular  can,  it  is  not  a  very  difficult  matter  to  locate  a  nurse  or  maid  or  orderly 
who  has  been  reckless  and  careless .  Where  this  sort  of  incinerator  is  employed  there 
is  a  concrete  floor  in  the  house,  just  in  front  of  the  furnace,  sloping  toward  the  center, 


Fig.  205. — Detail  of  garbage  burner. 

but  without  drainage,  the  purpose  being  to  collect  all  the  garbage,  including  the 
fluids,  and  with  a  specially  devised  shovel  the  whole  mass  is  thrown  into  the  tube. 
The  water  of  the  garbage  of  course  goes  out  as  vapor,  and  there  is  no  chance  for 
any  infected  matter  to  get  into  the  sewers,  because  in  the  evening  the  floor  is  thor- 
oughly carbolized  and  left  to  stand  over  night,  when  the  fluids  are  swept  over  the 
high  point  of  the  floor  and  into  a  sewer  runway  the  next  morning. 


THE    DESTR1  CTION    OF    WASTE 


029 


Combination  Garbage  Destroyer.— There  are  several  ma^es  of  furnace  adver- 
tised i"  permit  of  the  use  of  the  garbage  as  a  pari  of  the  fuel  for  heating  the  building. 
This  system  is  devised  for  small  hospitals.  Not  enough  is  known  definitely,  at 
least  by  the  author,  to  say  whether  there  is  any  economy  in  burning  garbage  as 
fuel  on  so  small  a  scale.  Many  good  engineers  testify  that  the  wetting  of  the  fires, 
and  the  consequent,  increased  amount  of  fuel  necessary  to  keep  the  boilers  going, 
will  more  than  overcome  any  saving  to  be  gained  by  the  use  of  the  dried  garbage  as 
fuel.  If  this  system  could  be  practised  on  a  very  large  scale  engineers  say  the  sav- 
ing would  be  considerable,  because  a  specially  devised  drier  could  be  utilized  for 


Ll 


Fig.  206. — The  Preston  house  incinerator. 


drying  the  garbage  before  attempting  to  use  it  as  fuel.  But  engineers  say  that  such 
a  system  would  resolve  itself  into  a  commercial  proposition,  and  its  value  be  depend- 
ent on  the  technical  handling  of  the  plant,  and  that  it  would  probably  save  nothing 
in  the  average  institution,  and  would  cause  much  inconvenience,  annoyance,  and 
possibly  lead  to  infections. 

The  Ward  Incinerator,  figure  206  shows  perhaps  the  best  example  of  garbage 
burner  to  be  utilized  at  various  points  about  the  institution.  The  manufacturers, 
J.  B.  Preston  &  Sous,  Webster,  Mass..  claim  lor  this  article  that  its  employment  is 
without  odor  and  without  any  dirt   whatever.      They  advertise  the  process  as  fol- 


630  OPERATION    OF   THE    HOSPITAL 

lows:  The  garbage  and  waste  of  all  sorts  are  thrown  in  at  the  top  of  the  burner,  and 
at  intervals  of  a  few  hours  the  gas  is  lighted  beneath  and  the  whole  contents  de- 
stroyed. There  are  a  good  many  of  us  who  might  have  in  mind  institutions  in 
which  such  a  process  could  not  be  carried  on  without  dirt  and  drippings,  and  there 
is  no  question  that  the  avenues  for  loss  are  thrown  wide  open.  No  one  is  present 
to  comb  over  the  contents  of  the  incinerator  and  retrieve  valuable  linens,  rubber 
goods,  and  other  articles  of  constant  use  about  the  service  rooms,  so  that  it  is 
greatly  to  be  doubted  whether  this  form  of  incinerator  will  not  conduce  to  reckless- 
ness and  carelessness  on  the  part  of  employees  and  nurses.  It  may  be  frankly  stated 
that  the  author  has  no  first-hand  knowledge  of  the  use  of  this  incinerator,  nor  has 
he  been  able  to  find  anyone  who  can  speak  at  first  hand  on  the  subject,  and  whose 
testimony  would  carry  weight  for  the  purposes  of  institution  management.  There 
are  a  great  number  of  these  incinerators  in  private  homes,  where  they  seem  to  be 
efficient  and  convenient. 


THE  INSTITUTION  BAKERY 

The  question  whether  an  institution  shall  bake  its  own  bread  or  buy  from  a 
commercial  bakery  is  one  that  will  have  to  be  answered  according  to  individual 
conditions.  In  the  very  small  hospital  undoubtedly  the  general  cook  can  bake 
what  bread  is  required  and  cook  whatever  pastry  will  be  needed,  and  the  cost  will 
be  covered  by  the  raw  material,  and  this  may  be  said  of  any  institution  that  is  not 
large  enough  to  require  a  professional  baker  and  a  regular  baking  plant.  As 
soon  as  a  regular  baking  organization  must  be  installed  the  expense  will  undoubtedly 
be  greater  than  it  would  be  to  purchase  the  bread  outright  from  a  commercial  baker. 
At  a  certain  size,  however,  it  may  well  come  to  pass  that  a  home  bakery  will  save 
money,  and  be  an  economy  from  other  standpoints;  that  is,  in  the  side  lines  that 
can  be  prepared,  such  as  cakes,  pies,  and  so  on. 

It  is  very  doubtful  if  the  average  institution,  especially  in  the  large  cities,  where 
competition  among  bakers  is  rather  keen,  will  save  any  money  by  baking  its  own 
breads  and  cakes.  In  the  Michael  Reese  Hospital,  where  the  goods  are  bought 
from  a  reliable  baker,  the  regular  purchases  are  about  as  follows  for  the  day: 

80  to  100  hotel  loaves. 

15  Viennas. 

16  home  made. 
7  rye. 

26  dozen  rolls. 

This  list  is  added  to  frequently  by  assorted  cakes  of  all  sorts  and  occasional  fancy 
pieces.  The  bill  of  the  hospital  averages  $9.89  per  day,  and  we  are  confidentially 
informed  by  our  baker,  and  we  believe  this  to  be  true,  that  there  is  a  net  profit  to 
the  baker  of  49  cents  per  day,  and  the  baker  divides  his  cost  as  follows: 

Material  consumed $6.40 

Labor 1.75 

Delivery 1.25 

$9.40 

If  it  is  intended  to  install  a  bakery  for  this  size  of  establishment,  the  equip- 
ment would  be  about  as  follows,  with  cost  of  each  piece: 

1  small  t  hree-deck  portable  oven  (gas) $140.00 

1  4-foot  steel  bread  trough 18.40 

1  trough  dividing  board 1.50 

1  trough  cover  (wooden) 3.75 

2  bread  peels  ($1.40  each) 2.80 

2  bread  boxes  ($2  each) 4.00 

2  cloth  covers  (60  cents  each) 1.20 

3(1  slock  pans  (35  cents  each) 12.60 

125  hotel  bread  pans 31.25 

1  hand  flour  sifter 7.50 

1  dough  Bcale 2.50 

1  30-inch  galvanized  bowl 6.00 

1  bowl  knife 50 

1  wash-bowl .35 

2  galvanized  pails  (20  cents  each) .40 

!  Quart  dipper .25 

1  Vienna  knife .25 

1  lolling  pin .35 

2  scrapers  (30  cents  each) .•'!t| 

I  bread  rack 25.00 

l  thermometer           L.25 

1  small  galvanized  proof  box 18,00 

1  small  single  pan  rack 10.00 

Total  cos!  of  equipment $288  t"' 

631 


632  OPERATION    OF    THE    HOSPITAL 

A  shop  of  this  size  would  require  a  space  35  by  20  feet.  The  expense  of  opera- 
ting would  be  as  follows  per  week  as  an  overhead  charge: 

Labor,  one  man  at §20.00 

Gas  for  oven 4.00 

Breakage  and  waste .90 

Depreciation  at  10  per  cent,  annually .55 

Interest  on  equipment  at  6  per  cent .26 

Total  weekly  operating  expense §25.71 

The  above  expenses  of  operating  would  be  practically  the  same  for  any  institution 
large  enough  to  require  a  special  baking  department.  Now  let  us  include  the  $6.40 
per  day,  or  §44.80  per  week,  the  actual  cost  of  the  material  consumed,  which,  with 
the  cost  of  operating,  amounts  to  $70.51 ,  or  a  small  fraction  over  §10  per  day,  against 
$9.89,  which  the  hospital  actually  pays  for  its  bread. 

This  does  not  mean  a  loss  to  the  baker,  however,  since  the  operating  expenses 
in  a  large  bakeshop  are  the  overhead  charges  for  baking  a  very  much  larger  amount 
of  bread.  For  instance,  the  baker  will  bake  for  several  institutions  as  large  as  the 
hospital  for  the  same  money,  and  perhaps  the  profit  to  the  baker  could  be  made  to 
show  a  profit  of  almost  as  much  as  the  total  operating  expense  of  the  hospital 
bakery. 

These  figures  seem  to  the  author  most  illuminating,  and  demonstrate  clearly 
that  a  hospital  bakery  does  not  pay,  even  assuming  that  every  batch  of  bread  started 
is  to  turn  out  right,  which  is  never  the  case.  Often  there  are  wastes,  whole  batches 
are  burned,  or  fail  to  rise,  or  are  in  some  way  spoiled.  Moreover,  with  ordinary 
hospital  machinery  it  is  impossible  to  guarantee  uniform  mixing  or  uniform  baking 
arrangements.  If  we  obtain  our  bread  from  a  baker  we  have  a  right  to  turn  it  back 
to  him  if  it  is  not  satisfactory. 

The  final  conclusion  is  that  in  an  institution  sufficiently  small  for  the  regular 
cook  to  do  the  baking  with  her  own  help,  home  baking  is  an  economy,  and  the  bread 
supply  will  cost  just  what  the  raw  material  is  worth,  plus,  perhaps,  a  little  extra 
gas  or  fuel,  but  that  there  will  never  be  a  saving  to  the  institution  that  runs  its  own 
bakery  when  it  is  large  enough  to  require  a  regular  baking  equipment. 


INDEX 


Am),  carbolic,  cost  of,  401 
Administrative  units,  40 
Admission  rooms,  40,  135,  340,  344 
Adrenalin,  373 
Adult  .lead  body,  378 
Aerating  beds,  94 
Air  cleansers,  102 

coolers,  103 

drafts,   L03 

intakes,  102 

operating-room,  103 

pressure  piping,  86 

supply,  83 

valves,  84 
Albumin,  382 

Alcohol  catgut  preparation,  364 
Aluminum  ware,  .569 
Alumnae  Associations,  307 
American  Civil  War,  304 

microscopes,  383 

plans,  ,'i7 

Sterilizer  Company,  164 

Ammonia  compression  system,  104 
Amphitheatre,  postmortem,  3.SS 
Andrews  Heating  Company,  '.15 
Anesthesia,  danger  signals,  375 

death  of,  374 
Anesthetic,  287,  288,  339,  369,  370 

choice  of,  371,  374 

cost  of,  372 

preparation  of  apparatus,  373 

purpose  of,  369 

staff,  369 

table,  equipment,  358 
Anesthetist,  339-368,  373 

\ne-i  hetizing  r n,  50 

Animal  cages,  389 

room,  388 
Annunciator,  91 

dumb-waiter,  93 

electric  lamp,  92 

elevator,  03 

interns',  93 

nurses',  93 
supervisory,  92 

\m  inieniiie.ii  ic  serum,  3S0 
Antisepsis,  305 


Antitoxins,  keeping  of,  404 
Apartments  for  patients,  111,  117 
Apomorphin,  cost  of,  401 
Apparatus,  86 

anesthetizing,  217 

cautery,  218 

gas  oxygen,  370 

heating,  SO,  83 

preparation  for  anesthetic,  373 

rebreathing,  371 

surgical,  184 
Appropriations,  21 
Arc  lights,  88 
Architectural  expenditures,  27 

mistakes,  33 
Architecture,  hospital,  33-156 

of  small  hospital,  140 

pavilion  style  of,  35 
Area  plans  per  patient,  40 
Arm  immersion  stand,  213 

rests,  184 
Arm-bake,  396 
Arnold  sterilizer,  3S3 
Arrangement,  medical  unit,  45 
Arteriosclerosis,  394 
Artificial  respiration,  375 

ventilation,  27 

water  cures,  393 
Asepsis,  82,  360 
Ash  handling,  81 

Ashby  Sewage  Disposal  Company,  95 
Association  support,  24 
Attending  physician,  381 

rules  for,  346 
Autoclave,  83,  163,  170 

laboratory,  383 
Automatic  stokers,  81 
Auxiliary  laboratories,  286,  381,  382 

medicine  cabinets,  402 

Baby,  care  of,  350 

Back-rests,   177.    Is:; 
Bacteria,  pathogenic,  383 

Bacteriology,  379  391 
Bakery,  83,   L16,  633 
Bakes  for  neuritis,  395 
Balance  sheet,  524 


634 


Bandages,  352,  353 

Basements,  51 

Bases,  coved,  64 

Basins,  temperature  of,  354 

Bath,  portable,  199 

waters,  temperature,  397 
Baths,  393,  394,  397 

for  insane,  397 
Bath-tubs,  95-98,  99 
Battey,  cystoscopic,  222 
Battleship  linoleum,  384 
Bausch  and  Lomb  microscope,  382 
Bed,  brass,  176 

cage  in,  182 

castors,  185 

cross-bar  of,  186 

hospital,  176 

linen,  599 

posts,  182 

rails,  179,  181 

raisers,  184 

raising,  difficulty  of,  184 

rollers,  185 

screens,  197 

slats,  178 
Bed-pans,  selection,  545 
Bed-rests,  183 
Bedside  annunciators,  91 

tables,  size  of,  187 
Bedsprings,  178 
Bell  signaling,  92 
Bernstein  bed  raiser,  185 
Beta-eucain,  354 
Bethesda  water  cure,  392 
Bichlorid  solution,  167,  353 
Billroth,  305 
Bills,  patients',  380 
Biologic  preparations,  keeping  of,  404 
Black  waxed  silk,  354 
Blakeslee  dishwasher,  230 
Blanket  warmers,  49,  80,  83,  159,  160 
Blankets,  purchase  of,  542 
Blood  count,  382-391 

pressure,  382-391 

stream,  394 
Board  of  directors,  248-252 
Bodies  for  morgue,  378 
Boilers,  80,  81,  83 

food,  83 

soup-stock,  231 
Boin  Steel  Range  Company,  235 
Bone  drill,  219 
Books  in  sick  room,  202 
Boric  acid  solutions,  353 
Bottles,  drug  store,  402 

laboratory,  402 


Bottles,  medicine,  400 

Box  springs,  178 

Bramhall  sterilizer,  169,  170,  183,  393 

Brass  beds,  187 

Bread  slicers,  232 

Breeding  cages,  389 

Brick,  53 

Brooms,  purchase  of,  578 

Brushes,  purchase  of,  579 

Buck's  extension,  184 

Building,  cost,  27 

Bunkers,  coal,   81 

Butcher  shop,  238 

Butter,  purchase  of,  556 

Cabaret  commode,  White  Line,  195 
Cabinet  baths,  394 

dressing-room,  224 

instrument,  215 

sterilizer,  172 

sweat,  396 
Caffein,  373 
Cages  for  animals,  389 
Calisthenics,  393 
Calling  nurses,  91 
Cameron-Wiley  Company,  95 
Camphor  compounds,  373 
Canned  goods,  imported,  566 
Capillary  congestion,  394 
Carbolic  acid,  5  per  cent.,  354 

cost  of,  401 
Carbon-dioxid  gas,  383 
Carbonic  acid  system,  104,  105 
Care  of  baby,  350 

of  children,  341 

of  mother,  349 
Carlsbad  baths,  393 
Carts,  dressing,  225 

irrigator,  212 
Casement  windows,  75 
Castor  oil,  cost  of,  401 
Catarrhal  affections,  20 
Catgut,  sterilization,  361-365 
Catheters,  care  of,  355 
Celloidin  microtome,  384 
Cement  roofs,  59 
Central  laboratories,  381 
Centrifuge,  electric,  382 
Ceramic  tiles,  65 
Cesspools,  95 
Chair,  commode,  194 

for  insane  persons,  195 

laryngologist's,  223 

ophthalmologist's,  223 

wheel,  faults  of,  193 
Chairs,  190 


035 


( lharacter  of  hospital,  20 
Charity  hospitals,  17-20 
patients,  food  for,  591 
Charlatinism,  393 

( 'lucks,  <loor,  79 

Chemical  solutions,  161,  169 

water  cure.-,  393 
Chemicals  for  catgut   preparation,  362 
Chicago  Surgical  ami  Electrical  Company,  217 
Chicory,  568 

Child,  bed  for.  size  of,  180 
dead  body  of,  378 

linens,  dishes,  dressings,  180 

thermometer,  ISO 

Children,  care  of,  341 
Children's  beds,  179 

bedside  tables,  188 

department,  general  rules,  340 

diseases,  20 

hospital.  3,  121,  139 

tables,  188 
Chinaware,  572 
Circulatory  diseases,  393 
Circumcisions,  345 
Classes  of  hospitals,  17 

Claudius'  method  of  catgut  preparation,  363 
Clay  tiles,  55 
Cleaning  the  hospital,  596 
Clinical  laboratories,  381 
Closet  bowl.  100 
Closets,  dressing,  135 
Clothing,  receptacles  for,  202 
Coal  elevators,  81 

supply,  Sl-85 
Coats  and  gowns,  purchase  of,  543 
Coeain  BC1,  353 
ColTce,  purchase  of,  ."ifiO 

urns,  83,  236 
Cold-water  pipes,  86 
Collodion,  378 
Columbia  University,  320 
Commercial  company  lighting,  82 
( lommode  chair,  194,  195 
Communicable  diseases,  20 
Community  needs,  17 
Composition  roofing,  59 

Co  I aled   piping,  St', 

( loncrete  foundations,  51 

ribs,  ."iii 

slabs,  55 

( londenaing  engines,  85 
( lonsenl  for  operation,  ■'•  15 
Construction,  hospital,  86,  139 

Containers,  hoi  -water,  20s 

Control  table,  397 
Conveyors,  i I,  s' 


Cooker,  vegetable,  234 
Cooking,  82 

utensils,  83,  568 
Copper  jacket  incubators,  383 
Coppenvare,  569 
Cork  floors,  66 
Corn,  purchase  of,  563 
Corporations,  railroad,  20 
Corridors,  36,  86 
Cost  of  building,  27 

of  drugs,  401 

of  small  laboratory,  391 
Cotton,  purchase  of,  539 
Couch,  nurses',  177 
Counters  for  pharmacy,  400 
Couveuse,  Child's  Hospital,  138 
Cove  bases,  64,  67 
Cows,  20 
Crimea,  304 
Cultures,  throat,  340 
Cunningham  position,  360 
Curled  hair,  padding  of,  179 
Curriculum,  305,  332,  334 
Cutlery,  purchase  of,  570 
Cystoscopic  battery,  222 

Dark  rooms,  387 

Death  reports,  378 

Decoration,  hospital,  78,  132,  200 

Department   of  hydrotherapy,  392 

of  pathology,  379 
Diagnosis,  379 
Diet  kitchen,  83,  170,  237 
Diets,  20 
Digalen,  373 
Dining-rooms,  116 
Directors,  board  of,  351 
Discharge  of  patients.  345 
Discipline  in  training-school,  310,  316 
Diseases,  children's,  20 

circulatory,  393 

communicable,  20 

ear,  20 

eye,  20 

gastro-inlestinal,  20 

infection-.  20 

lung,  20 

nose,  20 

of  nervous  system,  393 

throat,  20 

women's,  20 
Dish  heaters,  83,  227 

washers,  83,  228 
Disinfection,  161,  L65 
Disinfectors,  135,  168 
Dispensing  medicines,  400 


636 


Distribution  of  light,  87 

Divorced  women  as  probationers,  311 

Doctor's  call  system,  93 

orders,  322     . 
Donations,  21,  25 
Door  checks,  79 

frames,  77 

knobs,  79 

locks,  79 

screens,  198 

springs,  79 
Doors,  77 

Douche,  354,  394,  397 
Drainage-tubing,  355 
Drain-pipes,  93 
Drains,  bullet,  355 

cigarette,  355 

jacket,  355 
Dressing  boxes,  172,  378 

carts,  225 

rooms,  50,  83,  224 
Drinking-water,  refrigerated,  104 
Drug  refrigerator,  404 

stock,  401 

store,  400 
Drugs,  hypodermic,  375 
Drums,  172,  211,  212,  352 
Dry  heat,  394 

tap,  376 
Dumb-waiters,  110 
Duntley  vacuum  cleaner,  159 
Dust  catchers,  176 
Dusters,  purchase  of,  578 
Duty  on  instruments,  383 

Ear  diseases,  20 
Earnings  accounts,  522 
Eclipse  head  lamp,  223 
Eggs,  purchase  of,  554 
Electric  bells,  91 

centrifuge,  382 

drums,  211 

incubators,  383 

light  annunciator,  91 

plants,  81,  85,  87 

recorders,  92 

resetting  devices,  92 

thermometer,  397 

warming  pads,  87 
Elevator  doors,  109,  110 

safety  devices,  110 

signals,  93-110 
Elevators,  80,  81,  108 
Employees,  feeding  of,  582 

hiring  of,  592 

railroad,  20 


Employees,  trained,  593 
Employers,  20 
Enamel,  white,  176,  545 
Encaustic  tile  floors,  65 
Endowment  funds,  522 
Engineering  equipment,  82,  87 
Engines,  81,  85 
England,  graduate  nurses,  308 
Epidemics  in  rabbits,  388 
Equipment,  details  of,  79 

engineering,  82,  87 

for  hydrotherapy,  396 

kitchen,  83,  226 

laundry,  80 

milk  station,  133 

of  operating-room,  204 

steam,  83 
Ether,  369 

contra-indications,  374 

nitrous  oxid-oxygen,  370 
European  plans,  37 
Examination  rooms,  135 
Exanthemata,  163 
Excreta  sterilizer,  163 
Ex-interns  as  pathologists,  381 
Expenditures  account,  522,  524 

architectural,  27 

classified,  26,  29 
Expenses,  running,  28 
Exposed  piping,  86 
Eye  diseases,  20 

Facings,  52 

Families  of  workmen,  20 

Fans,  80 

Faucets,  Fuller  type,  100 

hot-water,  100 

operating-room,  97 

self-closing,  173 
Feeding  the  hospital,  582 
Felt  roofing,  59 
Fevers,  mountain,  20 
Filing  of  slides,  386 
Fillings,  roof,  59 
Filter-beds,  94 
Filterization,  triple,  173 
Financial  statement,  532 
Financing  the  hospital,  20 
Finishes,  wall,  78 
Fire  protection,  95 
Fireproof  material,  55 
Fish,  canned,  553 

purchase  of,  550 
Fixtures,  lighting,  86 

pharmacy,  400 
Flaxseed  meal,  cost  of,  401 


637 


Floor  construction,  55 
of  lulu  > r: 1 1 1  iries,  3S4 

pharmacy,  400 
plans,  37 

postmortem  room,  :is7 
Kin,, linn,  57,  ti(i,  132,  L36 
Florence  Nightingale,  304 
Food  boilers,  S3 

cars,  245,  246 

containers,  244 

milk,  20 
Foot  props,  177 
Foramen  of  Magcndie,  376 
Foreign  microscopes,  383 
Foreigners,  20 
Foreword,  33 
Formuldehyd,  ammonia,  164 

fumigation,  389 
Formalin  in  catgut  hardening,  363 
Formula  gauze,  352 

medicines,  400 
Foundations,  51 
Fowler  position,  186 
Frames,  door,  77 
Franklin  Company,  233 
Free  patients,  21 
Freezing  microtomes,  383 
Freight  lifts,  110 
Frozen  sections,  389 
Fruits,  canned,  565 

purchase  of,  558 
Fuel,  81 

Fumigation,  389 
Funds,  raising  of,  21 
Furnaces,  84 
Furniture,  87 
Furring,  73 

Garbage  cans,  382 

disposal,  626 
Garis-Cochrane  dish-washer,  230 
Gas,  administration,  371 

incubators,  383 

regulators,  383 
Cases,   161 

Gastrointestinal  diseases,  20 
Gauze,  medicated,  351-353 

purchase  of,  539 
Gelatin,  2  per  cent.,  353 
Gendron  Company,  19:> 
General  hospitals,  17-21 

rules,  337 
Genito-urinaxy  department,  20 
( (erman  sill  er  piping,  97 

water  cures,  392 
Gifts,  individual,  25 


Girders,  57 

( llass  fixtures,  401 

floors,  65 
Glassware,  546,  572 
Gloves,  rubber,  365,  368 
Glow  baths,  396 
Glycerin,  purchase  of,  401 
Goats,  20 

Goose-neck  reflector,  214 
Graduate  nurses,  308,  327,  330,  348 
Granite  mix,  53 
Graniteware,  568 
Green  oil  soaps,  575 
Greensfelder,  184,  214 
Guests,  feeding  of,  587 
Guinea-pigs,  388 
Gummed  labels,  402 
Gymnasium,  children's,  135 
Gynecologic  table,  225 

Hair  mattresses,  179 

Hall  stairs,  139 

Halls,  86 

Hamilton  Lowe  dish-washer,  230 

Hardware,  79 

Harrington  formula,  353 

Hartley  table,  207,  220 

Haustetter  (L.  A.),  230 

Head  lamp,  Eclipse,  223 

nurse,  313,  346 
Heads,  training-school,  316 
Heart  diseases,  393 

massage,  375 
Heat,  physics  of,  161 

prostrations,  392 

radiation  of,  172 

sterilization,  161 
Heating  apparatus,  SO,  86 
Heat-insulating  covering,  106 
Heister  gag,  373 
Help  in  hospitals,  30 
Hemoglobin,  3S2,  391 
Henderson,  371 
High  beds,  177 
High-pressure  steam,  86 
Hip,  fractures,  treatment  of,  184 
Hodgen  splint,  184 
Hollow  clay  tile,  55 
Holt's  bed,  182 
Home  life  of  pupil  nurses,  324 
Hoods,  laboratory,  384 
Hoppers,  168 

Horsehair  sutures.  :i."i  I 
llorslev's  wax,  :>.">  I 

I  Inspires  of  Europe,  304 

Hospital  architecture,  33,  36,  SO,  1  lit.  156 


638 


Hospital  beds,  180 

classes  of,  17,  21 

Clinical  Society,  300 

cost  per  cubic  foot,  155,  156 

decoration,  78 

financing  of,  20 

for  children,  132-139 

furniture,  176 

help,  30 

literature,  156 

maternity,  139 

pathology,  379 

pharmacy,  400 

problems,  17 

superintendent,  255 

Supply  Company,  207,  225 

support,  22 
Hospitals,  growth  in  number,  305 
Hotel  signalling  systems,  91 
Hot  water  in  operating-tables,  208 
Hot-water  heating,  84,  87 
House  count,  528 

medical  staff,  284 
Household  accounts,  523 
Housekeeper,  580 
Hydraulic  lift,  165 
Hydrotherapy  department,  392,  397 
Hygrometer,  216 
Hypodermic  tray,  373 

Ice,  104 

boxes,  laboratory,  390 
Illumination,  81,  87,  88 
Incandescent  lights,  89 
Income  account,  524 
Incubator  room,  138 
Incubators,  383 
Index  of  slides,  387 
Indirect  lighting,  87 
Infants'  department,  132 
Infants,  premature,  378 

stillborn,  378 
Infections,  20,  162,  361 
Infectious  department,  120 
Inoculation  cages,  389 
Insane,  chairs  for,  195 

water  cure  of,  397 
Insinger  dish-washer,  228 
Instrument  cabinet,  215 

room,  50 

sterilizer,  83,  174 

table,  213 

tray,  174 
stand,  211 
Instruments,  dressing,  358 

duty  on,  383 


Instruments,  laboratory,  382 

on  trays,  355,  357 
Insulation,  86 
Interior  lighting,  87 

painting,  78 
Interns,  300,  305 

beds,  183 

feeding  of,  584 

junior,  381 

rules  for,  347 
Introduction,  17 
Invalid  chair,  192 
Iodin  catgut  preparation,  362 
Iodoform  formulae,  352 
Irrigator  cast,  212 
Irrigators,  purchase  of,  546 
Isolation,  20,  340,  345 

building,  36,  288 

Janitor's  supplies,  577 
Jewelry  of  dead,  37S 
Johns  Hopkins  apparatus,  371 
Junior  intern,  286,  381 

Kangaroo  tendon,  365 
Kensington  Engine  Company,  164 
Kick  plates,  80 
Kitchens,  diet,  112,  133,  237 

equipment,  43,  83,  226 

location  of,  44 

management,  582 

ranges,  226 

sinks,  231 

table,  226 

utensils,  568 
Knobs,  door,  79 

Labarraque  formula,  353 
Labels,  gummed,  400,  402 
Labor  unions,  330 
Laboratories,  ward,  382 
Laboratory  animals,  388 

central,  381 

equipment,  382 

of  pathology,  170 

postmortems,  387 

technic,  381 
Lamp,  Eclipse  head,  223 
Lamps,  87 

Laryngologist's,  chair,  223 
Laundry  chutes,  624 

circulation  of,  613 

equipment,  598,  602,  620 

floor  plans,  607 

problems,  599 

rules,  608 


039 


Laws,  nursing,  331 
Lecture  rooms,  S6 
Leg  bake,  396 
rests.    184 

Legislators,  21 
Leitz  microscope,  3S2 
Lenses,  light,  88 
Lethal  point,  169 
Light,  S2 

for  postmortem  room,  387 

regulation,  87-S9,  90 
Lighting,  82-87 

fixtures,  89 

for  museums,  390 

laboratory,  387 
Linen,  bed,  599 

collectors,  620 

counting  rooms,  624 

handling,  612 

purchase  of,  541 

rooms,  621 

sterilizer,  162,  168 

typhoid,  169 
Linoleum,  62,  132,  190,  384 
Linseed  oil,  cost  of,  401 
Literature,  hospital,  156 
Lithotomy  position,  360 
Location  of  kitchen,  44 
Lockers,  43,  134,  202 
Locke's  solution,  354 
Locks,  door,  79 
Long  pack,  352 
Lysol,  354 

Magnesia  composition  floors,  66 

Maids,  nursery,  132 

Malaria,  20 

Male  nurses,  304,  335 

Malinekrndt  ether,  372 

Mangle,  604 

Marble  fixtures,  401 

tiles,  artificial,  64 
Marine  boilers,  80 

Married  women  as  probationers,  311 
Masks,  anesthetic,  371-373 
Massachusetts  General  Hospital,  388 
Massage,  :;7.">-396 
Maternity  department,  rules,  343-346 

Hospital,  20,  139,  140 

nurses,  rules,  3  17 
Mattress  sterilizer,  163 
Mattresses,  178 

Mayo's  operating-room,  205 

McArthur  (L.  L.),  207 

Meat  cutters,  232 
refrigerator,  238 


Meats,  purchase  of,  550 
Medical  schools,  381 

staff,  263 

students,  3S1 

unit,  arrangement  of,  45 

wards,  20 
Medicine  cabinets,  403 
Medicines,  400 
Meinecke  bed-pan,  546 
Menus  for  employees,  582 
Mercury,  catgut  preparation,  363 
Metal  doors,  7S 

rockers,  191 
Mice,  laboratory,  389 
Micro-organisms,  pathogenic,  169 
Mierophotography,  387 
Microscopes,  3S2 
Microtomes,  383 
Milch-goats,  20 

Militarism  in  nurse  training,  317 
Milk  food,  20 

station,  132 
Milling  terms,  20 
Mineral  springs,  392 
Mistakes,  architectural,  33 
Mixed  hospitals,  19 
Modern  trained  nurse,  304 
Modulating  systems,  S4 
Monolithic  cement  roofs,  59 

floors,  63 
Moore  light,  89 
Mops,  purchase  of,  578 
Morgue,  bodies  for,  378 

box,  378 

sheets,  378 
Morphin,  353-373 
Morris  chairs,  191 
Mosaic  floors,  64 
Mother  and  baby,  isolation  of,  345 

care  of,  349 
Motor  power,  80-82 
Motors,  SO 

Motl  control  table,  399 
Mountain  fevers,  20 
Museum  cases,  390 

lighting,  390 

pathologic,  390 

Nauheim  baths,  393 
Navy,  United  States,  214 
Needle  Bpray,  397,  399 
Meeds  <>f  community,  17 

Nephritis,  382 

NV«    York  City  Hospital,  211 
Nitrous  oxid,  370-374 
Noiselessness,  83 


640 


Non-condensing  engines,  85 
Nose,  diseases,  20 
Noxious  gases,  20 
Nursery  maids,  132 
Nurses  and  interns,  297 

beds,  183 

call,  91 

desk,  190 

dressing-room,  50 

feeding  of,  584 

modern  trained,  304 

rules  for,  360 

signals,  93 

table,  material  of,  190 
Nursing  mothers,  rockers  for,  191 

Oak  rockers,  191 
Oakum,  378 

Object-lesson  teaching,  324 
Obstetric  department,  20,  288 
Oil,  castor,  cost  of,  401 
Oilcloth,  190 
Oiled  muslin,  355 
Olives,  purchase  of,  566 
Open-door  policy,  276 
Operating  equipment,  208,  209,  358 
permit,  339,  345,  374 
rooms,  47,  82,  86,  87,  138,  169,  204,  351 

material,  162 

Michael  Reese,  205 

sinks,  214 
Operators,  338 
Ophthalmologist's  chair,  223 
Organization  support,  23 
Ostermoor  mattress,  179 
Oven,  paraffin,  384 

Pails,  purchase  of,  578 
Paint  for  laboratories,  386 
Painting,  children's  department,  132 

interior,  78 
Paracentesis,  377,  378 
Paraffin  microtome,  384 
Partitions,  71 
Passive  resistance,  395 
Pasteur,  305 
Pastry  kettles,  83 

pantry,  241 
Pathogenic  bacteria,  383 
Pathologic  Museum,  390 

sections,  390 

slides,  386 
Pathology,  department .  of,  379 

era  of,  305 

in  small  hospitals,  390 

surgical,  380 


Patients,  admission  of,  340,  344 

discharge  of,  345 

feeding  of,  586 

free,  21 

pay,  21 

position  on  table,  359 

preparation  of,  359,  374 

push  cord,  92 

rooms,  lighting,  87 
Pavilion  architecture,  35 

isolated,  36 
Pay  patients,  21 
Peas,  purchase  of,  561 
Pediatric  service,  288 
Pennsylvania  law,  331 
Perfection  bed-pan,  546 
Permit,  operating,  374 
Petty  cash  book,  525 
Pharmacy,  400 
Philanthropists,  19-21 
Photographic  studio,  387 
Physical  examinations,  341 
Physician,  attending,  346,  381 
Physiology  of  water  cures,  392,  395 
Pictures  in  sick  room,  201 
Pillows,  curled  hair,  179 
Pilot  light,  92 
Pipe  covering,  86 

shafts,  95 
Piping,  82,  83,  86,  100 

German  silver,  97 

water,  95 
Placebos,  400 
Planning  the  hospital,  36 
Plans,  American  hospital,  37 

European  hospital,  37 

floor,  37 

hospital,  142-156 

of  unit,  38 
Plaster  partitions,  71 
Plastering,  78 
Plastic  linoleum,  62 
Playground,  outdoor,  132 
Playroom,  children's,  135 
Plinths,  64 
Plumbing,  82,  93,  95 

control  table,  398 
Poisonous  drugs,  402 
Porcelain,  grades  of,  96 

sinks,  384 
Portable  bath,  200 

lamps,  87 
Portland  cement  roofs,  59 
Postmortem  amphitheatre,  388 

processes,  382 

room,  387 


641 


Postmortem  table,  388 

I'ijsI  operative  c-iimplicat  ions.   :iljS 

Posture  in  spinal  puncture,  370 

Potatoes,  purchase  of,  5(50 

Poultry,  purchase  of,  553 

Power  plant,  80,  81,  82,  85,  173,  523 

Practical  nurses,  308 

Frdiminary  training  of  nurses,  i09 

Premature  infants.  37^ 

Preparation  of  bodies,  378 

Prescript  ions,  compounding,  400 

Priestman  ejectors,  0-4 

Private  charity,  21 

homes,  children's  beds  in,  179 

hospitals,  19 

patients,  feeding  of,  591 

practice,  nurses  in,  329 

rooms,  117,  138,  177 
Probationers,  teaching  of,  318 
Provisions,  522 
Public  hospitals,  21 
Pumps,  vacuum,  84 
Purchase  of  medicines,  400 

of  supplies,  535 

Quartz  filter,  173 

Quasi-public  institutions,  24 

Quiet  rooms,  children's  department,  132 

Quincke  trochar  and  cannula,  376 

Quinin,  cost  of,  401 

Rabbits'  laboratory,  388 
Rack  solution,  213 
Radiators,  82,  S5 
Railings,  stair,  71 
Railroad  corporation,  20 

employees,  20 

hospitals,  20 
Raising  of  funds,  21 
Ranges,  kitchen,  226 
Rats,  laboratory  for,  389 
Receptacles  for  clothing,  202 
Record  books,  190 

of  patients,  92,  3S1 
Recreation,  310,  324 
Reflector,  goose-neck,  214 
Reflectors,  ss 

Refrigeration,  S6,  103,  238,  387,  390 
Regulating  valves,  8 1 
Regulators,  82,  84 

light,  90 
Reinforced  concrete,  55 
Religious  orders,  304 
Repair-,    52  I 
Reports,  daily,  538 

death,  378 
•11 


Requisition  form,  536 
Research  pathology,  379 
Respiration,  artificial,  375 
Resuscitation  in  anesthesia,  376 
Ringer's  solution,  354 
Rockers,  191 
Roof  fillings,  59 
Roofs,  55,  58 
Rooms,  admission,  40,  135 

charges,  380 

isolation,  children's,  132,  135,  341 

laboratory,  135 

milk  station,  133 

sewing,  134 

soiled  clothes,  134 

store-,  240 

surgical,  135,  138,  224 

wet  nurses',  132 
Rubber  blankets,  547 

floors,  65 

gloves,  365,  368 

goods,  care  of,  355 
purchase  of,  548 

sheets,  547 

tips,  190 

tissue,  355 
Rugs  in  hospitals,  197 
Rules,  anesthetics,  373 

children's  department,  340 

for  graduate  nurses,  328 

for  interns,  347 

for  maternity,  343,  347 

for  nurses,  360 

for  physicians,  279,  346 

for  technic,  337 

for  wet  nurses,  342 

general,  32S,  337 

surgical,  337 
Running  expenses,  2S 

Salaries  and  wages,  523 
Sanitorium,  baths  for,  397 
Sarah  Morris  Hospital,  132 
Scanlan  Morris  Company,  166,  195 
Schleich  formula,  353 
Schools  of  hydrotherapy,  392 

training-,  31)5 
Schott  exercises,  395 
Scouring  powders,  575 
Screens,  79,  198 
Senior  intern,  289 
Septic  tanks,  94 
Serums,  379,   390,    Hit 
Serving-rooms,  Hi.  s:;.  S7,  HI.  1S9,  242 
Sewerage,  93,  94,  168 
Shades,  87 


642 


Shelf  rack,  209 

stand,  equipment,  358 
Shipyards,  20 
Shone  ejectors,  94 
Shower-bath,  396,  399 
Sick  room,  books  in,  202 

pictures  in,  201 
Side  rails,  181 

rests,  184 

tables,  187 
Signalling  systems,  91 
Silk  sutures,  354 
Silverware,  purchase  of,  570 
Sims'  position,  360 
Sinks,  95,  100,  214,  231,  384,  388 
Site  of  hospital,  34 
Slate  floors,  65 
Slides,  382,  386 
Small  hospital,  equipment,  247 
food  for,  589 
pathology,  390 

laboratory,  cost  of,  391 
Smears,  340 
Soap  containers,  215 

marble  dust,  355 

purchase  of,  573 
Soil  pipes,  93 
Solution  rack,  213 
Solutions,  353 
Sound-proofing,  73 
Soup-stock  boiler,  231 
Special  hospitals,  291 
Specials,  undergraduate,  325 
Specimen  bottles,  385 
Specimens,  laboratory,  382 
Spencer  microscope,  382 
Spinach,  purchase  of,  564 
Spinal  puncture,  376 
Sponge  rack,  211 
Sponges,  351 

Spores,  anthrax  and  tetanus,  162 
Springs,  door,  79 

mineral,  392 
Squibb  ether,  372 
St.  Bartholomew's  Hospital,  306 
St.  Luke's  Hospital,  211 
Staff  anesthetists,  369 

engineering,  82 

members,  351 
Stair  hall,  139 
Stairs,  64,  69,  139 
Stand,  arm  immersion,  213 

drum,  211 
State  Nursing  Commissions,  331 
Steam,  physics  of,  161,  169 

supply,  80,  87 


Steam  tables,  83,  228,  242 
Steel  beams,  57 

casings,  77 

frames,  77 
Sterile  water,  82,  173 
Sterilization,  catgut,  362 

gloves,  367 
Sterilizers,  83,  161,  172,  383,  391 
Sterilizing  plant,  43,  48,  80,  247 
Steward,  hospital,  535 
Stillborn,  378 
Stock  cages,  389 

drugs,  401 

inventory,  538 
Stokers,  automatic,  81 
Storage-battery  signals,  92 
Storekeeper,  537 
Storerooms,  35,  240 
Street  Company,  233 
Students  as  technists,  3S0 
Sun  parlors,   117 

Superintendent  of  hospital,  253,  262,  295 
Superintendent's  diary,  526 

report,  531 
Supplies,  purchase  of,  535 
Supply  rooms,  49 
Support  of  hospitals,  22 
Surfacings,  floor,  60 
Surgeon's  private  assistant,  289 
Surgery  and  dispensary,  523 
Surgical  anesthetic,  268,  378 

department,  rules  for,  337 

dressing-rooms,  50,  83 

pathology,  380 

wards,  20,  47 
Swabs,  toothpick,  378 
Sweat  cabinets,  396 

Table,  postmortem,  388 

service,  584 

water,  control,  397 
Tables,  187,  226 

laboratory,  386 

steam,  83 

surgical,  206,  213,  325 
Tea  urns,  236 
Teachers  of  nurses,  318 

Technie,  hospital,  216,  305,  321,  337,  348,  380 
Telephone  system,  91 
Temperature,  control  valves,  84 
Terrazzo  floors,  64 
Test-tubes,  care  of,  385 
Tetanus  spores,  364 
Teter  apparatus,  217,  370 
Thermograde  systems,  84 
Thermometers,  397 


G43 


Thermostats,  S6 

Thiersch  formula,  353 
Three-shifl  service,  324 
Throat  diseases,  20 
Tile  pictures,  132 
Tiles,  55,  64 

Tinned  steel  utensils,  509 
Tomatoes,  purchase  of,  561 
Toothpick  swabs,  378 
Trained  nurse,  304 
Training-schools,  304 
Transfusion,  377 
Trays,  food,  242,  243 

hypodermic,  373 

surgical,  355 
Trendelenburg  position,  360 
Trial  balance,  528 
Troehar,  378 
Trustees,  351 
Tuberculosis,  163 
Tubing,  S9-185 
Tubs,  100 
Tungsten  lights,  90 
"Tutti  Colori"  floors,  64 
Two-shift  service,  324 
Types  of  incubators,  383 
Typhoid  fever,  163 

Undergraduate  specials,  325 
Uniforms,  purchase  of,  545 
Union  labor,  331 
United  States  Navy,  213 
Units,  electric  generating,  81 

plans  of,  38,  45,  47 
Urinals,  purchase  of,  546 
Urine  work,  379,  382 
Urinology,  390 
Urns,  coffee  and  tea,  236 
Utensil  sterilizers,  162,  165 
Utensils,  cooking,  S3 
Utility  rooms,  83 

Vaccine  therapy,  379 
Vaccines,  390 

keeping  of,  404 
Vacuo-vapor  systems,  84 
Vacuum  cleaner,  106,  157 

pump,  84,  107 

sterilization,  169 

systems,  84 
Valves,  S3 

Van  Born  and  Sawtell  catgut,  365 
Vapor  heat,  394 

systems,  84 
Vats,  169 


Vegetable  cooker,  234 

peelers,  232 
Vegetables,  canned,  562 

preparation  of,  5S4 

purchase  of,  560 
Venesection,  377 
Ventilation,  27,  83,  100 
Viaform,  352 
Victor  dish-washer,  230 

Electric  Company,  221 
Virchow,  305 
Visiting  nurse,  331 
Visitors,  337,  340,  344 
von  Eiselsberg,  369 


Wadding,  cut,  353 
Waiting-rooms,  135 
Wall  brackets,  S7 
Walls,  52,  55,  78,  132,  139 
Ward  chairs,  191 

laboratories,  381 

lighting,  S7 

medicine  cabinets,  402 
Wards,  20,  119,  120,  122,  128,  132,  ISO 
Wash-bowls,  95 
Wash-room,  50 
Wassermann,  380 
Waste,  destruction  of,  626 

pipes,  93 
Water  cures,  392,  397 

heating,  SO 

jacket  incubators,  3S3 

piping,  95 

sterilizers,  S3,  173 

tube  boilers,  81 
Water-closets,  100 
Waterproofing,  52 
Waxed  sutures,  354 
Weather  strips,  79 
Welsb'ch  lights,  3S7 
We,  dressing  box,  37S 
Wet -heat  catgut,  363 
Wet-nurses,  20,  191,  342 
Wheel  chairs,  192 
White  Dental  Manufacturing  Company,  21S 

Line  commode,  195 
sterilizer,  166 
Wholesale  drugs,  401 
Widal,  380 

Widow  as  probationer,  311 
Window-frames,  74 

sash,  74 
Window  s,  ~  I 
Women  as  technists,  3S0 

nurses,  304 


644 


Women's  auxiliary  boards,  251 

diseases,  20 

wards,  20 
Wood  fixtures,  401 

flooring,  57,  60 
Woodwork,  76 
Work-bench  paints,  386 
Work-benches,  386 


Workmen's  families,  20 

Woven  wire.  56 

Written  consent  for  operation,  339 

Yeoman's  ejectors,  94 


Zander  outfit,  132 
Zeiss  microscope,  382 


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